Chapter 14 Mental Health Services: Legal and Ethical Issues

Mental Health and the Legal System: An Overview Guided by ethical principles and state and federal laws Shifting Perspectives on Mental Health Law Liberal era (1960 to 1980) – Rights of persons with mental illness dominated Neoconservative era (1980 to present) – Emphasized limiting rights of mentally ill The Issues The nature of civil vs. criminal commitment Balancing ethical considerations vs. legal considerations The role of psychologists in legal matters Rights of patients and research subjects Practice standards and the changing face of mental health care

Civil Commitment: Overview, Criteria, and Oversight Authority Civil Commitment Laws Address legal declaration of mental illness Address when a person can be placed in a hospital or institution for treatment Such laws and what constitutes mental illness vary by state General Criteria for Civil Commitment Demonstrate that a person has a mental illness and needs treatment Show that the person is dangerous to self or others Establish a grave disability – Inability to care for self Governmental Authority Over Civil Commitment Police power – Protection of the health, welfare, and safety of society Parens patriae – State acts a surrogate parent

The Civil Commitment Process Initial Stages Person fails to seek help, but others feel that help is needed Petition is made to a judge on the behalf of the person Individual in question must be notified of the civil commitment process Subsequent Stages Involve normal legal proceedings in most cases Determination is made by a judge regarding whether to commit the person

The Concept of Mental Illness in Civil Commitment Proceedings Defining Mental Illness Is a legal concept, referring to severe thought or behavioral disturbances Not synonymous with a psychological disorder (DSM) Definitions of mental illness vary by state Mental retardation and substance-related disorders often are excluded Dangerousness to Self or Others: Central to Commitment Proceedings Assessing dangerousness: The role of mental health professionals Knowns and unknowns about violence and mental illness

Problems with the Process of Civil Commitment Early Supreme Court Rulings: Restrictions Over Involuntary Commitment A nondangerous person cannot be committed Need for treatment alone is not enough Having a grave disability is insufficient Consequences of Supreme Court Rulings Criminalization of the mentally ill Increase in homelessness Deinstitutionalization – Closure of several large psychiatric hospitals Transinstitutionalization – Movement of mentally ill to community care More Liberal Changes in Civil Commitment Procedures Followed

Subsequent Modification to Civil Commitment Procedures Civil Commitment Criteria Were Broadened Involuntary commitment for dangerous and non-dangerous persons Involuntary commitment for persons in need of treatment National Alliance of the Mental Ill argued for further reforms

Criminal Commitment: An Overview Nature of Criminal Commitment Accused of committing a crime Detainment in a mental health facility for evaluation of fitness to stand trial Found guilty or not guilty by reason of insanity

The Insanity Defense Nature of the Insanity Defense Plea Legal statement by the accused of not guilty because of insanity at time of crime Results in defendant going to a treatment facility rather than a prison Diagnosis of a disorder is not the same as insanity Definitions of Insanity M’Naughten rule – Insanity defense originated with this ruling Durham rule – More inclusive, involving mental disease or defect ALI Standard – Knowledge of right vs. wrong, self-control, and diminished capacity

Consequences of the Insanity Defense Public Misperceptions and Outrage John Hinckley Jr. found not guilty by reason of insanity (NGRI) 50% of states subsequently considered abolishing the insanity defense Public views – Insanity defense is a legal loophole Facts About the Insanity Defense Used in less than 1% of criminal cases Persons judged NGRI spend more time in mental hospitals than in jail Changes Regarding the Insanity Defense Insanity Defense Reform Act – Movement back to M’Naughten-like standards Guilty but mentally ill (GBMI) – Allows for treatment and punishment

Determination of Competence to Stand Trial Requirements for Competence Understanding of legal charges Ability to assist in one’s own defense Essential for trial or legal processes Burden of proof is on the defense Consequences of a Determination of Incompetence Loss of decision-making authority Results in commitment, but with limitations

Mental Health Professionals as Expert Witnesses The Expert Witness: Psychologists’ Role Person with specialized knowledge and expertise Evaluate imminent dangerousness (to a limited extent) Assist in making reliable DSM diagnoses Advise the court regarding psychological assessment and diagnosis Assess malingering (i.e., faking symptoms) Assist in competency determinations

Patient’s Rights: An Overview The Right to Treatment Mentally ill persons cannot be committed involuntarily without treatment Treatment includes active efforts to reduce symptoms and provide humane care The Right to the Least Restrictive Alternative Treatment within the least confining and limiting environment The Right to Refuse Treatment Often in cases involving medical or drug treatment Persons cannot be forced to become competent via taking antipsychotic medication The Right to Confidentiality vs. Duty to Warn Confidentiality – Protection of disclosure of personal information Tarasoff and the Duty to Warn – One of several limits on confidentiality

Research Participant Rights: An Overview The Right to be Informed About the Research Involves informed consent, not simply consent alone The Right to Privacy Right to be Treated with Respect and Dignity Right to be Protected from Physical and Mental Harm Right to Chose or to Refuse to Participate in Research Without Negative Consequences Right to Anonymity with Regard to Reporting of Study Findings Right to Safeguarding of Records

Clinical Practice Guidelines and Standards Agency for Health Care Policy and Research Focus on delivery of efficient and cost-effective mental health services Dissemination of relevant state-of-the-art information to practitioners Establish clinical practice guidelines for assessment and treatment American Psychological Association’s Practice Guidelines Standards for clinical efficacy research Standards for clinical effectiveness research

Summary of Ethical and Legal Issues in Mental Health Services Society Views and Laws About Mental Illness Change with Time Mental Illness Is a Legal Term, Not a Psychological Term Civil Commitment Is a Legal Processes Involving Involuntary Commitment Criminal Commitment Involves Criminal Behavior and Mental Illness Determination of competence, insanity, and criminal culpability Role of Mental Health Professionals in Legal Matters Rights of Patients, Research Subjects, and the Future of Mental Health Care