Every functioning criminal justice system faces the same foundational question: can a person who cannot understand what is happening to them be fairly tried for a crime? The American answer, rooted in centuries of common law and codified in Supreme Court precedent, is no. A defendant who lacks the mental capacity to understand the proceedings against them or to assist their own attorney cannot be tried, regardless of the evidence, regardless of the seriousness of the alleged offense.
That principle sounds clean. Its application is anything but.
Competency to stand trial (CST) sits at the intersection of criminal law, psychiatric evaluation, constitutional rights, and overwhelmed public health infrastructure. Courts are deciding it every day, often relying on forensic assessments conducted in conditions that bear little resemblance to the clinical environments those assessments were designed for. And across the country, a systemic crisis has quietly developed — one in which people found incompetent to stand trial are spending months and sometimes years in jails, untreated, legally stranded between a criminal process that cannot proceed and a mental health system too strained to receive them.
Key Takeaways
- The legal standard for competency to stand trial was established in Dusky v. United States (1960), which requires that a defendant have “sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding” and “a rational as well as factual understanding of the proceedings against him.”
- Competency is a present-tense assessment — it evaluates a defendant’s current mental state, not their state of mind at the time of the alleged offense, which is a legally distinct question governed by insanity defense law.
- Defense attorneys raise competency concerns in approximately 8–15% of felony prosecutions, and roughly 20–30% of defendants referred for evaluation are found incompetent to stand trial.
- A contested circuit split exists on a foundational procedural question: which party bears the burden of proving competency or incompetency at a competency hearing — a question the Supreme Court has repeatedly declined to resolve.
- In Missouri alone, 489 people were waiting in jails for competency restoration as of October 2025, up from just 10 in 2013 — with an average wait of 14 months and dozens imprisoned longer than the maximum sentence they faced.
- At least 16 lawsuits are currently pending against states for failing to provide timely competency evaluation and restoration services — and courts have imposed fines running into the hundreds of millions of dollars against states that have refused to comply.
The Dusky Standard: What the Law Actually Requires
The constitutional foundation for competency to stand trial is straightforward. Trying a person who cannot understand what is happening to them — or who cannot assist in their own defense — violates basic due process. It transforms a criminal trial into theater rather than justice.
The operational test comes from the Supreme Court’s 1960 decision in Dusky v. United States. The Court held that it is “not enough for the district judge to find that ‘the defendant is oriented to time and place and has some recollection of events.'” The test requires determining “whether he has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding — and whether he has a rational as well as factual understanding of the proceedings against him.”
Two things about the Dusky standard are worth holding onto. First, it is intentionally a low threshold. Competency is described in case law as “notoriously low” — a defendant does not need a sophisticated understanding of criminal procedure or a detailed grasp of trial strategy. What they need is enough functional capacity to understand the nature of the proceedings against them and to communicate meaningfully with counsel. A defendant who is actively psychotic, unable to distinguish their attorney from an adversary, or who believes the court is part of a conspiracy against them will typically fail this test. A defendant with a serious mental illness who is stabilized on medication may well pass it.
Second, competency is evaluated in the present tense — it describes the defendant’s current mental state, not their state of mind at the time of the alleged offense. That is an entirely separate legal question, addressed through insanity or diminished capacity defenses. A person can be fully competent to stand trial for something they did while deeply psychotic. The two inquiries coexist without contradiction.
How the Evaluation Process Works
When competency is in doubt — which can happen at any point in a criminal case, from arraignment through sentencing — a hearing is triggered. Under federal law (18 U.S.C. § 4241), either the defense or the prosecution can file a motion for a competency hearing. The judge can also initiate one independently based on courtroom observations. Many states require an automatic psychiatric evaluation once the issue is raised.
The evaluation is conducted by a forensic psychiatrist or psychologist who examines the defendant through clinical interviews, psychological testing, and review of medical and legal records. The findings are presented at a competency hearing, where the court — not the clinician — makes the ultimate legal determination. Judges typically give significant weight to the evaluator’s opinion, but they are not bound by it. They can also draw on their own courtroom observations of the defendant’s behavior.
Because competency is moment-specific, it can shift. A defendant found competent early in proceedings can subsequently become incompetent if their mental state deteriorates — as when a defendant who stabilizes on medication while in custody later stops taking it, becomes disorganized, and begins refusing to communicate rationally with their attorney. The issue can be raised again at any point.
The Contested Questions
Who Bears the Burden of Proof?
One of the most basic procedural questions in competency law remains genuinely unsettled. At a competency hearing, does the defendant bear the burden of proving they are incompetent, or does the government bear the burden of proving they are competent? The Supreme Court has addressed this question twice — and both times declined to resolve it definitively.
The result is an active circuit split. Different federal circuit courts have allocated the burden differently, meaning that which party must prove what at a competency hearing depends on where the case is being prosecuted — a state of affairs that raises obvious due process concerns. The University of Cincinnati Law Review analysis of this split concludes that the Supreme Court’s “passive stance” is creating due process violations through its inaction. Despite the circuit courts’ divergence, the Supreme Court has passed multiple opportunities to resolve it.
Forced Medication to Restore Competency
A second deeply contested area involves whether courts can order defendants to take antipsychotic medication against their will in order to restore their competency. The Supreme Court addressed this in Sell v. United States (2003), establishing a four-part test for when such forced medication is constitutionally permissible.
Under Sell, involuntary medication to restore competency requires that the government demonstrate: (1) important governmental interests are at stake; (2) the medication will significantly further those interests; (3) the medication is necessary and less intrusive means are unavailable; and (4) administration of the medication is medically appropriate. The bar is high by design — the individual’s liberty interest in avoiding unwanted administration of antipsychotic drugs is a recognized constitutional right under Washington v. Harper (1990).
In practice, Sell hearings are relatively uncommon, but they arise in high-stakes cases where a defendant is not dangerous enough to justify forced medication for safety reasons, but where the government wants to proceed to trial. The standard’s application is contested at every step — courts frequently disagree about what constitutes a “serious enough” charge to invoke the governmental interest, whether proposed medications are “likely” to restore competency, and whether side effect risks make a specific regimen medically inappropriate.
What “Rational Understanding” Actually Means in Complex Cases
The Dusky standard requires rational understanding, but courts have disagreed about what that means for defendants with paranoid or delusional thinking that is specifically directed at their own case. A defendant who generally understands the legal system but believes their attorney is a government plant conspiring against them presents a genuine puzzle: they have factual knowledge but may lack the rational understanding the standard requires.
Indiana v. Edwards (2008) added another wrinkle, holding that a defendant can be found competent to stand trial without being competent to represent themselves. The standard for self-representation can be higher than the standard for competency to stand trial with counsel — meaning that courts can require attorney representation for defendants who have cleared the Dusky threshold but whose mental illness would undermine their ability to conduct their own defense.
The Restoration Crisis: A System at Its Limits
When a defendant is found incompetent to stand trial, the case cannot proceed. The defendant is committed to a period of treatment — called competency restoration — intended to bring their mental state to a point where they can meaningfully participate in their own defense. In the federal system, initial hospitalization is capped at four months, with extensions if there is a substantial probability of restoration in the foreseeable future. Under Jackson v. Indiana (1972), the Supreme Court held that indefinite commitment based solely on incompetency is unconstitutional — the state must either restore the defendant to competency, release them, or initiate ordinary civil commitment proceedings.
That constitutional framework assumes a functional mental health system capable of providing timely treatment. What has developed instead is a national crisis.
Missouri had just 10 people on its competency restoration waitlist in 2013. By October 2025, that number had grown to 489, with an additional 200 people waiting just to be evaluated after a court had ordered an evaluation. The average wait for admission to a treatment facility had grown from eight months to fourteen months in just two years. Missouri’s Supreme Court Chief Justice Mary Russell warned in her 2024 State of the Judiciary address that “concrete cell blocks are not conducive for treating mental health or addiction issues.” A dozen people were jailed longer waiting for restoration than the maximum sentence they faced for their charged crimes. Timothy Beckman, 64, schizophrenic and living in nursing homes because he could not care for himself, was jailed after breaking into a home and eating a burrito. He was found incompetent and placed on a waitlist. After eight months in a Kansas City jail, he accidentally choked to death on food.
Texas saw its waitlist for competency restoration grow to more than 2,700 people at its peak. A state audit found that at least 54 people died waiting for treatment between 2018 and 2023.
Washington State has been in contempt of federal court orders related to competency services for years. A federal judge fined the Washington Department of Social and Health Services $100 million in 2023 for failing to provide adequate and timely mental health services. Despite years of litigation, injunctions, consent decrees, and contempt fines, the state had consistently failed to meet court-ordered timelines.
Oklahoma settled a federal class-action lawsuit in 2024 over its competency restoration failures, agreeing to binding deadlines and expanded services. By mid-2025, the system was described by the lead plaintiff’s attorney as being “in total free fall” — with the Department of Mental Health facing a $30 million budget gap, its director having been fired, and wait times remaining months long despite the court order.
At least 16 lawsuits are currently pending against states — including Alabama, California, Colorado, Florida, Mississippi, Texas, and Utah — for failing to provide timely competency evaluation and restoration. The pattern is consistent: courts find violations, impose fines, issue orders, and states return with new proposals for the same inadequate system.
The National Conference of State Legislatures’ primer on competency is blunt about the situation: individuals charged with a crime can spend longer in jail awaiting competency evaluation or restoration services than they would if convicted and given the maximum sentence for the underlying charge. They are presumed innocent. They are not receiving punishment. They are receiving what amounts to indefinite pretrial detention — in conditions often far worse than those that would follow conviction — because the system meant to treat them is too under-resourced to function.
Why It’s Contested Beyond the Legal Questions
The competency system draws criticism from multiple directions simultaneously, and those criticisms do not all point in the same direction.
From defense advocates, the concern is that the system traps mentally ill people in jails where their conditions worsen rather than improve, that restoration-focused treatment in forensic settings is inadequate compared to genuine psychiatric care, and that the standard’s low threshold means many defendants with serious mental illness are found competent and proceed to trial with impaired ability to participate in their own defense.
From prosecutors and victims’ advocates, there is concern that competency proceedings can be weaponized as delay tactics, that the system allows dangerous individuals to remain in legal limbo without accountability, and that some defendants cycle repeatedly through findings of incompetency and restoration without ever being meaningfully held responsible.
From forensic mental health professionals, the concerns are methodological: competency evaluations vary enormously in quality across jurisdictions, the Dusky standard is vague enough to generate genuine clinical disagreement, and evaluators are sometimes asked to conduct assessments under conditions — brief jail encounters, incomplete records, rushed timelines — that undermine the reliability of the findings.
From constitutional scholars, the unresolved circuit split on burden of proof represents a fundamental inconsistency that means the same defendant could be found competent or incompetent depending entirely on which court has jurisdiction — a result that sits uneasily with any conception of equal protection.
The NACDL’s ongoing competency resource project identifies the system as one requiring fundamental reform, noting that “the processes for evaluating and restoring competency can be lengthy and complex, varying widely across jurisdictions” in ways that produce unjust outcomes regardless of the good intentions of individual participants.
Looking Forward
Some states are beginning to experiment with alternatives. Colorado’s 2024 Bridges Wraparound Care Program attempts to divert eligible defendants from traditional competency proceedings into community-based support services — reducing reliance on inpatient forensic beds and shortening jail wait times. As of early 2026, 15 judicial districts in Colorado are operating specialized competency dockets serving over 1,700 clients.
Jail-based competency restoration programs — providing treatment and education within jails rather than requiring transfer to a state hospital — are being piloted in several states, with mixed results. They address the immediate bottleneck but raise their own concerns about whether jail environments can provide genuine treatment or merely the appearance of it.
The fundamental problem is structural. The competency system was designed to interface with a robust public mental health infrastructure. That infrastructure has been steadily defunded for decades. The number of psychiatric hospital beds in the United States has declined from approximately 559,000 in 1955 to fewer than 38,000 today. The gap between the legal system’s demands and the mental health system’s capacity has been filled, increasingly, by jails. And jails are not hospitals. They cannot restore competency. They can only warehouse people until a hospital bed opens — or until those people deteriorate beyond restoration.
The constitutional guarantee of competency to stand trial remains robust in theory. The infrastructure required to make that guarantee meaningful is, in much of the country, in collapse.
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