Chapter 16 Mental Health Services: Legal and Ethical Issues

1. Chapter 16Mental 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; Two Eras • Liberal (1960 to 1980) – Rights of mentally ill dominated • Neo-conservative (1980-onwards) – Limit rights of patients • 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 evolution of mental health care

3. 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 • 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 • Governmental Authority Over Civil Commitment • Police power – 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 • 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 • Subsequent Stages • Involve normal legal proceedings in most cases • Should a person be committed? • This determination is made by a judge

5. The Concept of Mental Illness inCivil Commitment Proceedings • Defining Mental Illness • A legal concept – Severe disturbances • Not synonymous with a psychological disorder • Definitions of mental illness vary by state • Often excluded conditions include • Mental retardation and substance-related disorders • 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

6. 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 • 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

7. Britain Bedlam

8. 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

9. 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

10. 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 • Definitions of Insanity • M’Naughten rule – Insanity defense originated here • Durham rule – More inclusive definition • Mental disease or defect • American Law Institute Standard • Knowledge of right vs. wrong • Self-control • Diminished capacity

11. 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 • 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 • Movement back to M’Naughten-like standards • Guilty but mentally ill (GBMI) • Allows for treatment and punishment

12. 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

13. 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

14. The Role of Expert Witness inCivil 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)

15. 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 • The Right to Refuse Treatment • Often in cases involving medical or drug treatment • Persons cannot be forced to become competent for trial • The Right to Confidentiality vs. Duty to Warn • Confidentiality – Protect disclosure of information • Tarasoff and the Duty to Warn – Limits on confidentiality

16. 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 • Right to Anonymity in Report of Study Findings • Right to Safeguarding of Records

17. 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 • American Psychological Association’s Practice Guidelines • Standards for clinical efficacy research • Standards for clinical utility (effectiveness) research

18. Summary of Ethical and Legal Issuesin 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 • 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