Chapter 14 Mental Health Services: Legal and Ethical Issues

Civil Commitment: Overview, Criteria, and Oversight Authority  Civil Commitment Laws – Legal declaration of mental illness – When can a person be placed in a hospital for treatment? – Such laws and definitions of mental illness vary by state

Civil Commitment: Overview, Criteria, and Oversight Authority (continued)  General Criteria for Civil Commitment – Person has a mental illness and needs treatment – Person is dangerous to self or others – Grave disability – Inability to care for self

Civil Commitment: Overview, Criteria, and Oversight Authority (continued)  Governmental Authority Over Civil Commitment – Police power – Health, welfare, and safety of society – Parens patriae – State acts a surrogate parent

The Civil Commitment Process  Initial Stages – Person fails to seek help – Others feel that help is needed – Petition is made to a judge on the behalf of the person – Individual must be notified of the commitment process

The Civil Commitment Process (continued)  Subsequent Stages – Involve normal legal proceedings in most cases – Should a person be committed? – This determination is made by a judge

The Concept of Mental Illness in Civil Commitment Proceedings  Defining Mental Illness – A legal concept – Severe disturbances – Not synonymous with a psychological disorder – Definitions vary by state – Often excluded conditions include  Mental retardation and substance- related disorders

The Concept of Mental Illness in Civil Commitment Proceedings (continued)  Dangerousness to Self or Others – Central to commitment proceedings – Assessing dangerousness -- 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 on involuntary commitment – A non-dangerous person cannot be committed – Need for treatment alone is not enough – Having a grave disability is insufficient

Problems with the Process of Civil Commitment (continued)  Consequences of Supreme Court Rulings – Criminalization of the mentally ill – Increase in homelessness – Deinstitutionalization – Large psychiatric hospitals closed – Transinstitutionalization – Mentally ill to community care  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  For persons in need of treatment  National Alliance of the Mentally 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 – Focus on fitness to stand trial – Found guilty or not guilty by reason of insanity

The Insanity Defense  Nature of the Insanity Defense Plea – A Legal Statement – Accused of not guilty because of insanity at time of crime – Defendant sent to a treatment facility rather than prison – Diagnosis of a disorder is not the same as insanity

The Insanity Defense (continued)  Definitions of Insanity – M’Naughten rule – Insanity defense originated here – Durham rule – More inclusive definition – American Law Institute Standard  Knowledge of right vs. wrong  Self-control  Diminished capacity

Consequences of the Insanity Defense  Public Misperceptions and Outrage – John Hinckley Jr. found not guilty by reason of insanity – 50% of states – Moved to abolish the insanity defense – Public views – Insanity defense is a legal loophole

Consequences of the Insanity Defense (continued)  Facts About the Insanity Defense – Used in less than 1% of criminal cases – Spend more time in mental hospitals than in jail  Changes Regarding the Insanity Defense – Insanity defense reform act – Guilty but mentally ill (GBMI)  Allows for treatment and punishment

Therapeutic Jurisprudence  Overview – Using knowledge of behavior change  To help those in trouble with the law  “Problem Solving” Courts – Address unique needs of people with specific problems – Examples include delayed sentencing under the condition the individual holds a job for six months

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

Duty to Warn  What to do if a client threatens to harm another person?  Tarasoff v. Regents of the University of California – Must warn individual in danger  Thompson v. County of Alameda – Threats must be specific  When in doubt, consult with colleague

The Role of Expert Witness in Civil and Criminal Proceedings  The Expert Witness: Psychologists’ Roles – Person with specialized knowledge and expertise – Assist in competency determinations – Assist in making reliable DSM diagnoses – Advise the court  Regarding psychological assessment and diagnosis – Assess malingering (i.e., faking symptoms)

Patient’s Rights: An Overview  The Right to Treatment – Cannot be involuntarily committed without treatment – Treatment – Reduce symptoms and humane care  The Right to the Least Restrictive Alternative – Treatment within the least confining and limiting setting

Patient’s Rights: An Overview (continued)  The Right to Refuse Treatment – Often in cases involving medical or drug treatment – Persons cannot be forced to become competent for trial

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

Research Participant Rights: An Overview (continued)  Right to Chose or to Refuse to Participate in Research  Right to Anonymity in Report of Study Findings  Right to Safeguarding of Records

Clinical Practice Guidelines and Standards  Agency for Health Care Policy and Research – Efficient and cost-effective mental health services – Dissemination of relevant state-of-the-art information  To practitioners and the general public – Establish clinical practice guidelines  For assessment and treatment

Clinical Practice Guidelines and Standards (continued)  American Psychological Association’s Practice Guidelines – Standards for clinical efficacy research – Standards for clinical utility (effectiveness) research

Summary of Ethical and Legal Issues in Mental Health Services  Societal Views and Laws About Mental Illness – Have changed over time  Mental Illness Is a Legal Term, Not a Psychological Term  Civil Commitment Is a Legal Processes – Involves involuntary commitment

Summary of Ethical and Legal Issues in Mental Health Services (continued)  Criminal Commitment – Involves criminal behavior and mental illness – Involves competence, insanity, and criminal culpability  Role of Mental Health Professionals in Legal Matters  Rights of Patients and Research Subjects  The Future of Mental Health Care