CH-16-Mental Health Services – Legal & Ethical Notes

Perspectives on Mental-Health Law

• Mental-health law constantly balances two sets of rights/responsibilities:
  • Rights of persons with psychological disorders (autonomy, liberty, dignity).
  • Society’s duty to protect and provide care (public safety, public health).
• Historical “eras” in U.S. law (LaFond & Durham, 1992):
  • Liberal era (≈ 1960–1980): priority on individual rights & procedural fairness.
  • Neoconservative era (≈ 1980–present): emphasis on public safety, "law & order."
• Conceptual overlap of legal, ethical, research obligations (e.g., confidentiality in both therapy & research).
• Illustrative case: “Arthur” (brief psychotic disorder) – family unable to commit him because no imminent danger.

Civil Commitment

• Definition: Legal process allowing involuntary hospitalization & treatment of persons meeting statutory criteria.

Historical Evolution

• 19th-century state hospital system ➜ abuses (e.g., Mrs Packard committed for “dangerous” religious views).

Statutory Criteria (common to most states)

1. Presence of a “mental illness” requiring treatment.
2. Dangerousness to self OR others.
3. Grave disability (inability to care for basic needs).

• “Mental illness” in statutes ≠ DSM-5 disorder (varies by state; often excludes substance use & intellectual disability).

Two Government Powers

• Police power – protect public welfare.
• Parens patriae – state acts as “surrogate parent” to protect individuals unable to act in own interest.

Procedures

• Petition (family/professional) ➜ judicial hearing ➜ legal counsel, right to jury, notice, presence, cross-examination.
• Assisted Outpatient Treatment (AOT): court-ordered community treatment as alternative to inpatient.
• Emergency (“clear & present danger”) holds allow short-term detention without full hearing.

Dangerousness

• Popular belief: mental illness ⇒ violence; research: only modest risk ↑; key co-factors = substance use, anger, recent stress.
• Assessment tools (e.g., PCL-R) good at ruling OUT high risk, less accurate predicting specific future violence.

Landmark U.S. Supreme Court Cases

• O’Connor v. Donaldson (1975): cannot confine non-dangerous person able to survive with help.
• Addington v. Texas (1979): involuntary commitment requires more than promise of improved life; dangerousness standard raised.

Deinstitutionalization & Consequences

• Goal: close large hospitals & create community mental-health centers.
• Reality: \approx 75\% reduction in state-hospital census, but community resources lacking.
• Trans-institutionalization: movement from hospitals ➜ nursing homes, shelters, jails.
• Homelessness: 2\text{–}3 million experience at least one night/yr; >400{,}000 nightly; severe mental illness in \approx30\%.
• Criminalization: justice system absorbs untreated individuals (jail > hospital ratio >3:1).

Legislative Reactions

• Late 1970s/80s some states broadened criteria (e.g., Washington 1979 “need for treatment” ➜ 91\% ↑ in involuntary admissions).
• Sexual predator laws (post-1990, upheld in Kansas v. Hendricks 1997): civil commitment after prison if still “dangerous.”

Criminal Commitment & the Insanity Defense

• Criminal commitment = confinement because (a) accused awaits competence determination, or (b) acquitted NGRI.

Insanity Standards

Public Perception vs Reality (Silver et al., 1994)

• Belief: insanity plea in 37\% felonies; actuality <1\% (0.9\%).
• Belief: 44\% of pleas succeed; actuality 26\%.
• Majority of NGRI acquittees hospitalized (actual \approx85\%); confinement often > prison term.

High-Profile Case: John W. Hinckley Jr. (1981)

• Found NGRI using ALI ➜ national backlash; Insanity Defense Reform Act (1984) – federal return to narrow M’Naghten-like test; burden on defendant.

Guilty but Mentally Ill (GBMI)

• Hybrid verdict; sentenced as guilty, treatment may precede prison; research: longer incarceration, little extra treatment.
• Some states (ID, MT, UT) abolished insanity plea, retain GBMI.

Competence to Stand Trial

• Dusky v. U.S. (1960): must understand proceedings & assist counsel.
• Incompetent defendants confined until competence restored (Jackson v. Indiana 1972 limits duration).
• Medina v. California (1992): defendant bears burden to prove incompetence.

Therapeutic Jurisprudence & Problem-Solving Courts

• Drug, mental-health, domestic-violence courts aim for behavior change using empirically based interventions; roots in tribal justice models.

Duty to Warn / Protect

• Tarasoff v. Regents (1976): clinicians must warn identifiable victim of credible threat.
• Thompson v. Alameda (1980): no duty for vague, nonspecific threats.
• Ethical best practice: seek consultation, document risk-management.

Mental-Health Professionals as Expert Witnesses

• Roles: risk assessment, competence, diagnosis, malingering detection.
• Short-term violence predictions (2–20 days) reasonably reliable; long-term forecasts weak.
• MMPI validity scales effective at detecting malingering.
• Concerns: “hired gun” bias; must stay within expertise.

Patients’ Rights

Right to Treatment

• Wyatt v. Stickney (1972): minimum standards (staff ratios, sanitation, active treatment).
• Least Restrictive Alternative standard articulated.
• Youngberg v. Romeo (1982): confirmed right to safety & non-restrictive care; deference to professional judgment.
• Protection & Advocacy for Mentally Ill Individuals Act (1986): state P&A systems investigate abuse/neglect.

Right to Refuse Treatment

• Focus on antipsychotics (efficacy vs severe side-effects e.g., tardive dyskinesia).
• Riggins v. Nevada (1992): cannot forcibly medicate solely to render defendant competent; must show medical necessity.
• Washington v. Harper (1990): involuntary meds permissible after due-process “Harper hearing.”
• Applied in Jared Loughner case (2011 Tucson shootings).

Rights of Research Participants

• APA Ethical Principles (2010):
  • Informed consent, privacy, dignity, protection from harm, voluntary participation, anonymity, record security.
• Greg Aller/UCLA case illustrates complexities of medication-withdrawal studies & consent capacity.

Evidence-Based Practice (EBP) & Clinical Practice Guidelines

• EBP: integrate best research evidence, clinical expertise, patient values.
• U.S. Agency for Healthcare Research & Quality (AHRQ) coordinates guideline development; ACA (2010) & Patient-Centered Outcomes Research Institute expand mandate.

Two-Axis APA Template (2002)

1. Clinical Efficacy Axis (internal validity)
   • Hierarchy:
     A. RCT shows superior to alternative active tx.
     B. Superior to nonspecific therapy.
     C. Superior to no-treatment control.
     D. Quantified clinical observations/replication series.
     E. Expert consensus.
2. Clinical Utility Axis (external validity)
   • Feasibility (cost, acceptability, compliance, dissemination).
   • Generalizability across populations, therapists, settings.
   • Cost–benefit to individual & society.

Goals

• Identify treatments that work AND can be delivered widely & economically ➜ reduce overall health-care costs (\text{e.g.,}\; avoid ineffective care).

Key Numerical Facts & Equations

• Homeless severe mental illness proportion: \approx 30\%.
• Public vs actual use of insanity plea: 37\% vs 0.9\% of felonies.
• Insanity plea success: 44\% perceived vs 26\% actual.
• Hospitalization reduction after deinstitutionalization: \approx 75\%.
• Washington state 1979 law ➜ 91\% ↑ in involuntary commitments first year.
• Ratio: for every NGRI verdict, \approx45 incompetence commitments (Butler 2006).

Illustrative Cases & Examples

• Arthur (brief psychosis) – highlights commitment threshold.
• Joyce Brown (“Billie Boggs”) – homelessness vs autonomy debate.
• John Hinckley Jr. – catalyst for Insanity Defense Reform Act.
• Kenneth Donaldson – O’Connor precedent.
• Sex-offender civil commitment – Kansas v. Hendricks.
• Greg Aller – informed consent in research.

Ethical, Philosophical, Practical Implications

• Tension between autonomy & paternalism: parens patriae vs right to refuse.
• Stigma & bias (e.g., racial disparities in involuntary commitment).
• “Brain blame” debates: neuroimaging evidence in court (psychopathy, empathy circuits).
• Cost containment driving EBP; clinicians must adapt to guideline-driven care.

Connections to Broader Psychology

• Links with neuroscience (empathy & prefrontal cortex damage ➜ moral decisions).
• Application of assessment tools (PCL-R, MMPI) from clinical to forensic settings.
• Influence of social policy on clinical practice (deinstitutionalization ➜ community care models).

Concept-Check Answers (from text)

1. Civil-commitment blanks: mental disorder, dangerous, grave disability, legal, deinstitutionalization, transinstitutionalization.
2. Criminal-commitment blanks: (a) competence to stand trial, (b) diminished capacity, (c) ALI rule, (d) Durham rule, (e) M’Naghten rule, (f) malingering, (g) expert witness, (h) duty to warn.
3. Guidelines blanks: (1) clinical efficacy, (2) clinical utility, (3) informed consent, (4) reduce costs, (5) refuse treatment.