photo - COLORADO SPRINGS, CO - December 09: Robert Dear Jr. looks back into the gallery during one outbursts during a court appearance on December 09, 2015 where El Paso County prosecutors filed formal charges against him in the Planned Parenthood attack during which University of Colorado Colorado Springs police officer Garrett Swasey, Iraq war veteran Ke'Arre Stewart and Jennifer Markovsky, mother of two were killed on November 27, 2015. Photo by Andy Cross/The Denver Post
COLORADO SPRINGS, CO - December 09: Robert Dear Jr. looks back into the gallery during one outbursts during a court appearance on December 09, 2015 where El Paso County prosecutors filed formal charges against him in the Planned Parenthood attack during which University of Colorado Colorado Springs police officer Garrett Swasey, Iraq war veteran Ke'Arre Stewart and Jennifer Markovsky, mother of two were killed on November 27, 2015. Photo by Andy Cross/The Denver Post 

Planned Parenthood shooter Robert Lewis Dear Jr. remains incompetent to stand trial, but can be forced to take medication if he refuses treatment, prosecutors said in court Thursday.

While the competency ruling by a Colorado Springs judge means the case remains on hold, prosecutor Donna Billek alluded to coming "changes" brought on by an Aug. 17 order by Pueblo District Judge Jill S. Matoon permitting the Colorado State Mental Health Institute at Pueblo to medicate Dear against his will.

Mental health experts warn that hopes of an immediate turnaround in Dear's mental condition could be overly optimistic.

"Based on what I've seen with this type of case, I think the prognosis is probably very guarded," said Nicole Schneider, a forensic psychologist who has performed hundreds of evaluations related to competency and sanity issues. Schneider hasn't evaluated Dear and has no personal ties to the case against him.

Dear's case has been on hold since May 2016, when a judge concluded that Dear, 59, has been unable to separate fact from fiction for decades.

Although antipsychotic medications can produce a change in people suffering delusional disorder - Dear's diagnosis by his state treatment team - the longer they've held delusional beliefs, the more difficult the road ahead.

"You have to go very slowly," said Max Wachtel, an Aurora-based forensic psychologist who has done 600 to 700 mental competency evaluations. "Honestly, a lot of it in the beginning is just rapport and relationship building and getting the person to trust you. And then hopefully, as the medication starts to work, you can very slowly start to gently challenge the person's delusions."

Even with medication, it's a process that can take months or even years, Wachtel said.

In another wrinkle, Dear's defense attorneys say they will work to block the order to medicate Dear against his will, requesting the Pueblo judge to put off her order pending an appeal.

Although Dear is being prosecuted in El Paso County, Pueblo District court has jurisdiction over mental health proceedings involving the state hospital in Pueblo. Hospital officials initiated the request for forced medications, Billek said in court.

The incompetency ruling means that the courts have ruled that Dear does not have a rational understanding of the case against him and is therefore ineligible for trial. Competency refers to his current mental state; it is different from the question of his sanity at the time of the offense. And because Dear has yet to enter a plea in the case, it is unclear whether his attorneys will argue that he was insane at the time of the shootings. Also unresolved is whether prosecutors will seek the death penalty should the case be on track for trial.

Thursday's hearing marked a rocky first appearance by Dear before a new judge, 4th Judicial District Chief Judge William Bain, who succeeds retired Chief Judge William Martinez.

Dressed in a green T-shirt and jeans, Dear's conduct suggested little has changed from prior court appearances.

"Jesus said there would be signs in the sun, the moon and the stars," he said as he shuffled into court. "That's what the eclipse was. Judgment is next."

Dear repeatedly lashed out at the judge for not allowing him to speak, telling Bain that his name means "poison."

"I looked it up!" he told the new presiding judge.

The Hartsel man is charged with 179 counts in a Nov. 27, 2015, shooting rampage at Colorado Springs' lone Planned Parenthood clinic. Three people were killed, including a University of Colorado at Colorado Springs police officer, and nine were wounded.

Dear is due to return to court Nov. 21 for another competency update.

Gazette reporter Jakob Rodgers contributed to this story.

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