Lecture 13: Professional Issues

When psychopathology “gets legal”

  • Definition of psychopathology invokes concepts of distress, dysfunction/ impairment, there are implications for justice, protection of affected persons.

  • Psychopathology affects many domains, including cognition, with implications for the:

    • Ability to discern right from wrong (‘know’ the criminality of an act), and/ or participate in/understand a legal process (for justice to be served).

    • Ability to consent to/make decisions about various matters / contracts, including decisions about treatment

    • Examples:

      • A condition affecting self-perception (such as an eating disorder) that is severe (starvation/threat to life), can this person decide their treatment?

      • A condition that affects perceptions, with reality distortion (think of active psychosis), can this person discern right from wrong (be held responsible for their actions)?

      • A condition that affects information-processing including new learning (e.g., neurocognitive disorder due to Alzheimer disease), can this person understand ‘criminal proceedings?’

  • The “vulnerability” of affected persons may identify a role in “vetting” or “regulating”, via the law, the health professionals / workforce that provide services.

Who needs protecting & why?

Because of illness a person may lack the capacity to:

  • initiate or comply with treatment when it’s needed (e.g., to avoid self-harm, harm to others)

  • make treatment decisions (e.g., such as whether or not to have electroconvulsive therapy)

  • understand legal charges (e.g., so that they are not mistakenly held criminally responsible)

Forms of protection I

  • Protections vary in their formality/legal status.

  • To illustrate, vulnerable patients may be protected by tools:

    • that professionals voluntarily subscribe to (such as a health professional’s “code of ethics”), or

    • that the professional is legally bound by (e.g., “a licence to practice” or mandatory reporting obligations) → psychology registrations

  • The form of protection depends on why it is needed.

Code of ethics - Examples

  • Voluntary professional codes of conduct are a form of protection. A professional code of ethics is an example.

  • Applies to the clients of practitioners who are “bound” by these codes.

  • Protects the vulnerable by outlining professional standards that clients can expect (e.g., how confidential disclosures will be protected).

  • A breach is not “illegal”; but the act could be and might be investigated/referred.

  • Australian psychology code has three underpinning principles

Professional Registration I

  • Mandatory mechanisms – such as ensuring that mental health practitioners are registered to practice – is used to help protect the public and vulnerable people.

  • A legal tool, primarily aimed at protecting the public

  • It’s mandatory: it protects everyone who sees a registered health practitioner.

  • Some health practitioners are registered (e.g., psychologists and psychiatrists) but others are not (e.g., counsellors or life coaches).

Professional registration II

  • How does registration serve as a protection

    • The term “psychologist” is protected

    • Public protection via annual assessments including:

      • training requirements

      • criminal check

      • health check

Professional Registration III

If professional responsibilities are breached, this may lead to claims of

  • Negligence

  • Malpractice

Breaches may lead to criminal sanctions, disciplinary action, reprimands so that unsafe practitioners can be managed (e.g., deregistered / practice conditions imposed)

Forms of protection III

Patient rights statements may express:

  • Right to treatment

    • In the least restrictive alternative environment

  • Right to refuse treatment

    • Informed consent

    • Proxy decision making (e.g., guardians, advocates)

    • Entitlement to second opinion regarding treatment

    • Refusal of medication (more controversial)

Forms of protection IV

  • Involuntary/Civil commitment

  • Insanity defense (and variants of it including, guilty but mentally ill)

  • Competence to stand trial

Ethics meets the law III

  • In Queensland, the law [Mental Health Act] recognises three patient “types”.

    • “Involuntary”. This person has not consented to assessment or treatment for mental illness, but is compelled to participate – by law.

    • “Classified”. This person is in custody and they become unwell, any pending criminal proceedings are ‘suspended’. The Act authorises their detention in a secure mental health facility with access to care (voluntary or involuntary capacity).

    • “Forensic”. This person has been charged with a serious offence, and a decision has been made about the offence (case is “acquitted”). The court determines that they were “of unsound mind” (not criminally responsible) or they are unfit to stand trial due to a ‘mental condition’. The Act may require treatment (inpatient/community etc).

Involuntary assessment criteria

  • Appears to have mental illness (as defined by the Act)

  • Requires immediate treatment

  • Risk of harm (or deterioration) to self or others

  • No less restrictive way to assess

  • Lacks capacity to consent or has unreasonably refused to be assessed

  • Assessment can be properly made by an authorised mental health service

Insanity defense: helping? I

  • Community impression: “widely used”, “getting off lightly”

  • In fact:

    • Not widely used, hard to “win” [upheld in 25% of cases].

    • Being a “forensic patient”: is it a “light” penalty or a “legal monstrosity”?

  • Forensic patients typically spend the same time in care (“committed”), as people spend in prison, and sometimes the period of committal is longer.

Why the misperceptions?

  • Is this due to a misunderstanding of ‘insanity’, or differences in the way that insanity is defined clinically versus in the eyes of the law?

  • Does this mean that the law has a paradoxical effect on people with mental illness?  Rather than protecting them, do perceptions about this defense actually impair its use (people don’t try it, even when they should)?

Forms of protection

  • The deprivation of liberty (including the ordering of involuntary treatment) is serious matter.

  • The framing of the law that enables this deprivation to be legal may offer another protection for those affected

  • The Mental Health Act, 2016 says that the powers exercised under it the should:

    • Occur only if there is no less restrictive way to protect health and safety.

    • Be enacted in such a way that negative effects on liberty and rights are minimised.

  • Commonly used if the person is determined to be a danger to themselves or others.

Mental illness prevention

  • In the literature, preventative efforts can be classified as

    • Universal (for everyone, e.g., school based consent programs)

    • Selective (for high risk groups, e.g., body image programs for adolescent girls)

    • Indicated (for high risk individuals, e.g. a person who experienced a potentially traumatic event)

Global Mental Health

  • The area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide

  • Recognises the extensive suffering and contribution of mental illness to global burden of disease and quality of life

  • Seeks to support a transformation in ways that mental illness is viewed within society—a restored sense of humanity

  • Most mental health research and programs have been developed with, and for (?), more economically developed countries

  • Significant gaps

    • Many people in some countries don’t get the mental health treatment they need

    • Gaps are largest in low- and middle-income countries [LMICs]

    • Human rights abuses against affected individuals

    • Need for scale-up of services

Balanced Care Models

  • Low- and Middle-Income Countries (LMICs): 80% of world’s population; 20% of world’s mental health resources (Patel & Prince, 2010).

  • Resources can be provided at 4 levels: community through tertiary. In high income countries, like Australia, supports at all levels may be available

  • Levels vary by:

    • reach [more people can benefit from community resources]

    • specialisation [tertiary resources are the most specialist; for people with the severest conditions]

•In LMICs with multiple resource constraints, including availability of specially trained staff, community services may appeal (i.e., require fewer specialist staff, can be offered to more people at an earlier illness stage).

Psychosocial/non-pharmacological treatment and advice

  • Psychoeducation

  • Addressing current psychosocial stressors

  • Reactivate social networks

  • Structured physical activity programme

  • Offer regular follow-up

  • Pharmacological interventions

Stigma and treatment gaps

  • Some progress in Western contexts with reducing stigma & increasing resources for mental health treatment, MHT (e.g., > 10% of USA health spending is on MHT)

  • Despite some progress, stigma persists everywhere for some illnesses (e.g., psychosis, mental disability, dementia)

  • LMICs, require similar changes:

    • Less than 2% of expenditure on health goes to services for psychiatric conditions in countries in Africa, Latin America and Asia

    • Stigma is high which means human rights abuses, social isolation & exclusion, stigma for individuals and families

What can be used for LMIC? SUNDAR

  1. Simplify messages

  2. Unpack our interventions

  3. Delivered as close as possible to people’s homes

  4. Recruit and train Available human resources from the local communities

  5. Re-allocate the scarce and expensive resource of mental health professionals to train, supervise and support community health agents

Summary:

  • There is a significant global mental health burden, borne primarily by people in LMICs. There are many challenges for care, including resourcing, stigma, availability of trained/specialist/ ‘registered’ staff, raising consideration of resource allocation.

  • Low-resource intense prevention programs can operate at multiple points before diagnosis/treatment; they may target wider social environmental and economic factors and can be adapted to overcome barriers (SUNDAR).

  • The challenge of global mental health & provision of evidence-based care involves

  • A tightrope of recognising utility of systems alongside their limits, and

  • Recognition of the cultural, social, and contextual influences on our current understanding of mental health, its causes, consequences and treatments

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