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If defendants are unable to adequately understand or participate in their defence as a result of a mental disorder, they can be found unfit, or incompetent, to stand trial. In this event, the trial is suspended until the defendant’s fitness is restored. Since at least the 17th century, the provision of fitness has been recognized; it was established to protect the reliability and accuracy of a trial, the dignity of the criminal justice system, and the effectiveness of punishment (1). Fitness to stand trial assessments are the most common type of pretrial evaluations (2,3). American research indicates that between 2% and 8% of all felony defendants are referred for fitness assessments (4–6). In 1982, Webster and colleagues estimated that 5000 fitness evaluations were conducted yearly in Canada (7), and more recent research has documented an increase in these evaluations (8). Because convictions can be overturned in cases in which a defendant was potentially incompetent and was not evaluated, it is rare for a judge to refuse a request for an evaluation (1). Assessment ModelsBased on Canadian law, fitness assessments can be broken down into several components (9). First, the evaluator must assess the defendant’s mental state to determine whether he or she has a mental disorder. Second, an evaluator must investigate whether the defendant demonstrates impairment in 1 or more of the necessary legal abilities required to stand trial. If defendants have both impaired psycholegal abilities and a mental disorder, and if the impaired abilities are thought to be caused by the mental disorder, they can be found unfit to stand trial. In the past, the emphasis was placed on the first of these questions; namely, on the evaluation of a defendant’s mental health. Clinicians drew upon general clinical theories to provide the framework for fitness evaluations and implemented traditional assessment methods, including unstructured clinical interviews and intelligence and personality tests (10–12). The second question—with respect to whether a defendant had impaired legal abilities—was overlooked, ignored, or incorrectly inferred from psychopathology (10,13–16). The most blatant example of this was the tendency of clinicians to equate the mere presence of a psychotic disorder with unfitness (11,17). Fitness assessment practices have substantially changed in the past 2 decades. Recent research indicates that psychoticism is no longer commonly equated with incompetency (18–20), and evaluators generally address the basic legal issues (15). Evaluators continue to be criticized, however, for providing inadequate information about defendants’ legal abilities (10,15,21–24). This neglect of the relevant legal abilities on the part of evaluators conducting fitness assessments is not surprising. While the general training of mental health professionals prepares them to assess whether a defendant has a mental disorder, it generally does not prepare them to assess legal abilities (Note 1). Nevertheless, this is the critical aspect of the evaluation. In response to this dilemma, the functional model of evaluation was proposed (10–11,25). This model recognizes that the primary purpose of fitness assessment is to describe the functional abilities that are required for a defendant to stand trial, in contrast to most clinical assessments, which have as their primary goals the determination of diagnoses and the recommendation of interventions. To assess these functional abilities, this model recommends that clinicians use specialized forensic assessment instruments. These instruments are intended to add to, rather than replace, more traditional methods and have numerous benefits (10). Most significantly, perhaps, these instruments help evaluators maintain a proper focus. They also provide structure and consistency, thereby potentially increasing the reliability of judgments and reducing the possibility of bias. Since the late 1960s, several forensic assessment instruments have been developed (for reviews of these instruments, see 1 and 6). The forensic assessment instrument that is the focus of the present study is the Fitness Interview Test (FIT). Qualifications of EvaluatorsAlthough ultimately it is the court’s responsibility to determine whether an individual is unfit to stand trial, traditionally, courts have relied heavily upon the opinions of mental health professionals (1,15,26). Historically, only physicians were permitted to evaluate fitness. Since the 1940s, the ability of psychologists and other mental health professionals to evaluate fitness has been increasingly recognized in the US (27–33). A recent survey indicated that 47 states allow psychologists to evaluate fitness, 15 allow social workers, and 9 allow nurse practitioners and others (34). Conversely, in Canada, legislation requires that only physicians conduct court-ordered fitness evaluations (35). Other mental health professionals are occasionally involved in other aspects of these assessments. Psychologists, for example, may be requested to conduct psychological testing, which is then incorporated into physician reports (36). Likewise, psychologists and social workers have acted as expert witnesses in court cases involving fitness to stand trial (37–39). The question of who is qualified to assess fitness is a contentious issue. Psychologists, in particular, have argued for recognition as evaluators (28,40). Research has supported this argument by demonstrating that mental health professionals from various disciplines can achieve high levels of reliability, validity, and quality in fitness assessments (1,15,27,41–45). Only a few of these studies, however, have directly compared the abilities of various disciplines to make these determinations (42,44). One goal of the present research was to evaluate the abilities of various professional groups to make determinations of fitness, using a semistructured instrument. Fitness Interview TestThe FIT, revised edition, is a semistructured clinical interview that comprises 16 items (9). It takes approximately 30 minutes to administer and is designed to be a screening instrument that would ideally be administered on an outpatient basis to screen out defendants who are clearly fit to stand trial. Within this framework, defendants whose fitness is considered questionable would be referred for additional assessment. The original version of the FIT, which was developed in 1984, was revised; it is now divided into 3 sections, paralleling the 3 legal criteria for fitness to stand trial outlined in the 1992 amendments of the Criminal Code of Canada. These include understanding the nature and object of the proceedings (1,2), understanding the possible consequences of the proceedings, and the ability to communicate to counsel (3). Given that these criteria are similar to those used in other countries, including the US and England (46,47), the FIT appears appropriate for use outside Canada. Items and sections on the FIT are rated on a 3-point scale. Although performance on the individual items contained in a section is considered in the determination of the section rating, decisions are not made based on a cut-off score. Instead, the section ratings constitute a separate judgment based on the severity of impairment and its perceived importance. The last step in FIT administration is to make a final determination of the defendant’s fitness. This determination must be made in conjunction with mental health information. To evaluate FIT validity, Zapf and Roesch compared decisions made by the FIT with decisions made in an institution-based evaluation of fitness (48). They found that the FIT correctly identified 49 of the 57 male defendants in their sample (86%) as either fit or unfit. They emphasized that it is extremely important that screening instruments do not make false-negative errors (that is, call a defendant “fit” who is truly unfit), because this could conceivably result in an unfit defendant being tried unfairly. In this respect, the FIT performed extremely well, in that it made no false-negative errors. Later studies found that the FIT demonstrated excellent agreement with institution-based decisions (49), and appropriate levels of agreement with other fitness assessment instruments (50). To date, no research has investigated the interrater reliability of the FIT. This was the primary purpose of the present study. The second purpose of this study was to assess the feasibility of obtaining reliable FIT ratings by the following 4 professional groups: 1) physicians, 2) psychologists, 3) graduate students in psychology, and 4) nurses.
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