1. Chapter 14 Mental Health Services: Legal and Ethical Issues

2. Mental Health and the Legal System: An Overview
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

3. 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

4. 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

5. 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 (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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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