Chapter 14
Mental Health Services: Legal and Ethical Issues
Mental Health and the Legal System: An Overview
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Mental Health and the Legal System
– Guided by ethical principles and state and federal laws
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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
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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
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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
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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
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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
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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
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Defining Mental Illness
– Is a legal concept, referring to severe thought or behavioral
disturbances
– Not synonymous with a psychological disorder (DSM)
– 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
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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
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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
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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
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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
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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
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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
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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
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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
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Consequences of a Determination of Incompetence
– Loss of decision-making authority
– Results in commitment, but with limitations
Mental Health Professionals as Expert Witnesses
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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
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The Right to Treatment
– Mentally ill persons cannot be committed involuntarily without treatment
– Treatment includes active efforts to reduce symptoms and provide humane
care
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The Right to the Least Restrictive Alternative
– Treatment within the least confining and limiting environment
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The Right to Refuse Treatment
– Often in cases involving medical or drug treatment
– Persons cannot be forced to become competent via taking antipsychotic
medication
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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
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The Right to be Informed About the Research
– Involves informed consent, not simply consent alone
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The Right to Privacy
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Right to be Treated with Respect and Dignity
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Right to be Protected from Physical and Mental Harm
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Right to Chose or to Refuse to Participate in Research Without
Negative Consequences
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Right to Anonymity with Regard to Reporting of Study Findings
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Right to Safeguarding of Records
Clinical Practice Guidelines and Standards
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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
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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
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Society Views and Laws About Mental Illness Change with Time
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Mental Illness Is a Legal Term, Not a Psychological Term
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Civil Commitment Is a Legal Processes Involving Involuntary
Commitment
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Criminal Commitment Involves Criminal Behavior and Mental Illness
– Determination of competence, insanity, and criminal culpability
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Role of Mental Health Professionals in Legal Matters
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Rights of Patients, Research Subjects, and the Future of Mental Health
Care