Mental Health Services Legal and Ethical Issues Chapter

Mental Health Services: Legal and Ethical Issues Chapter 14

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

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 – 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

Emotion regulation strategies • • • supression – very inefficient way to deal with emotions, epecially anger – physiological consequences of suppression are similar to expressing anger in an open way (changes in hearth rhythm, high arousal, lack of oxygen to the heart) denial – good emotion regulation strategy at the beginning, after a trauma – not good in the long-run (leads to chronic stress) reapraisal – means changing the way we think about an emotionally challenging event – it helps to restructure the problem in a meaningful way, gives the situation a meaning and leads to relieve – the most adaptive way to regulate emotions with the least negative physiological effects – good to combine this strategy with stress management or meditation/relaxation techniques