Chapter 14 Mental Health Services: Legal and Ethical Issues

1
Chapter 14 Mental Health Services Legal and
Ethical Issues
2
Mental Health and the Legal System An Overview

• Mental Health and the Legal System
• 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

3
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

4
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

5
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

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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

7
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

8
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

9
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
• MNaughten 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

10
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
  MNaughten-like standards
• Guilty but mentally ill (GBMI) Allows for
  treatment and punishment

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Determination of Competence to Stand Trial

• Requirements for Competence
• Understanding of legal charges
• Ability to assist in ones 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

12
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

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Patients 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

14
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

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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 Associations Practice
  Guidelines
• Standards for clinical efficacy research
• Standards for clinical effectiveness research

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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