Chapter 16: Mental Health Services: Legal and Ethical Issues

Civil commitment laws

• detail when a person can be legally declared ti have a mental illness and be placed in a hospital for treatment

• involves legal definition of mental illness

• Date back to late 19th century

• Laws vary by state

Civil Commitment General Criteria

• Person has mental illness and needs treatment

• Person is dangerous to self or other

• Person is gravely disabled

• Inability to care for self

Governmental authority over civil commitment

• Police power - health, welfare, and safety of society

• Parents patriae - state acts as surrogate parent ( a person receives care to prevent them from being in danger)

Initial stages of Civil Commitment Process

• Person fails to seek help

• Others feel that help is needed

• Peititon is made to a judge on behalf of the person

• Individual must be notified of the commitment process

Subsequent Stages of Civil Commitment Process

• Involve normal legal proceedings in most cases

  • Determination is made by a judge

  • Decision informed by expert opinions

Mental Illness as a Legal Concept Excludes

• cognitive disability

• substance-related disorders

Mental Illness as a Legal Concept is defined as

severe emotional or thought disturbances that impact health and safety

The definition of Mental Illness as a Legal Concept is not synonymous with having a psychological diagnosis

• Benefit: flexibility

• Disadvantage: Vulnerable to bias

Violence and Mental illness

• Misconception that people with mental illness are much more likely to be dangerous- perpetrated by sensational media portrayals

• Substance use disorder and recent victimization increase likelihood of violence

• People with mental illness are more likely to be victims of violent crimes than those without mental illness

Asssessment tools are

best at identifying people at low risk of being violent; not good at long term prediction (OK at short term)

Can professional predict whether any individual will become violent?

No

Supreme Court has placed restrictions on involuntary commitment

A non-dangerous person can’t be involuntarily commitment

Consequences of Supreme Court Rulings

• Criminalization of the mentally ill

• Deinstitutionalization

• Transinstitutionalization

Deinstitutionalization

• Movement of people with mental illness out of institutions

• Problem: led large numbers of ill people to become homeless

Transinstitutionalization

In practice, people with mental illness have been moved out of large mental hospitals to other institutions, including prisons and nursing homes

Nature of Criminal Commitment

• Accused of committing a crime

• Detained in mental health facility

  • Evaluation determines fitness to stand trial

• Can be found guilty, not guilty, or not guilty by reason of insanity

  • Or more recently, “guilty but mentally ill”

Nature of the insanity defense plea

• The accused is not guilty because of insanity at time of crime

• Diagnosis of a disorder is not the same as insanity

• Frequently portrayed in popular media but actually very rare

M’Naghten rule

inability to distinguish right from wrong

Durham rule

Crime was the product of mental illness

American Law Institute Standard

Knowledge or right vs wrong; self-control; diminished capacity (reduced ability to understand their behavior)

What caused public outrage about the Insanity Defense?

• After John Hinckley Jr (who tried to assisinate Reagen) was found not guilty by reason of insanity, 75% of states moved to abolish or change the insanity defense

• Public views insanity defense as a legal loophole

Facts about the insanity defense

• Use 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 by mentally ill (GBMI)

  • Allows fo treatment and punishment

Therapeutic Jurisprudence

Using knowledge of behavior change to help those in trouble with the law

“Problem solving” Courts

• Address unique needs of people with specific problems

• Ex: Drug treatment courts, domestic violence courts, and mental health courts

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

Tarasoff v. Regents of the University of California

Must warm individual in danger

Thompson v. County of Alameda

Threats must be specific

Psychologists’ role as expert witness

• Person with specialized knowledge and expertise

• Assist in competency determinations

• Assist in making reliable DSM diagnoses

• Advise the court regarding psychological assessment and diagnosis

• Asssess malingering (ex: faking symptoms)

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 (Ex: by taking medications)

Research Participants Rights

• 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 choose or to refuse to participate in research

• Right to anonymity in report of study findings

• Right to safeguarding of records

Increased cost of health care leads

governments to study effectiveness of treatment

Past 15-20 years - Evidence Based Practice (EBP) formally identified as

systematic method of delivering clinical care

Agency for Healthcare Research and Quality

• Efficient and cost-effective mental health services

• Dissemination of relavent state of the art information

• Clinica efficacy axis

• Clinical utility axis

Clinical efficacy axis

involves thorough consideration of scientific evidence to determine whether intervention is effective compared to alternative treatment

Clinical utility axis

is concerned with the effectiveness of the intervention in the practice setting (ex: are results generalizable to real world)

What percentage of felony indictments result in an insanity plea? (Public perception)

37.0%

What percentage of felony indictments result in an insanity plea? (Actual Occurrence)

0.9%

What percentage of insanity pleas result in an acquittal? (Public perception)

44.0%

What percentage of insanity pleas result in an acquittal? (Actual Occurrence)

26.0%

What percentage of insanity acquittees are sent to a mental hospital? (Public perception)

50.6%

What percentage of insanity acquittes are sent to a mental hospital? (Actual occurence)

84.7%

What percentage of insanity acquittes are freed? (Public perception)

25.6%

What percentage of insanity acquittes are freed? (Actual occurence)

15.3%