1. Chapter 16 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; Two Eras
Liberal (1960 to 1980) – Rights of mentally ill dominated
Neo-conservative (1980-onwards) – Limit rights of patients
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 evolution of mental health care

3. Civil Commitment: Overview, Criteria, and Oversight Authority
Civil Commitment Laws
Legal declaration of mental illness
When can a person be placed in a hospital for treatment?
Such laws and definitions of mental illness vary by state
General Criteria for Civil Commitment
Person has a mental illness and needs treatment
Person is dangerous to self or others
Grave disability – Inability to care for self
Governmental Authority Over Civil Commitment
Police power – 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
Others feel that help is needed
Petition is made to a judge on the behalf of the person
Individual must be notified of the commitment process
Subsequent Stages
Involve normal legal proceedings in most cases
Should a person be committed?
This determination is made by a judge

5. The Concept of Mental Illness in Civil Commitment Proceedings
Defining Mental Illness
A legal concept – Severe disturbances
Not synonymous with a psychological disorder
Definitions of mental illness vary by state
Often excluded conditions include
Mental retardation and substance-related disorders
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 on involuntary commitment
A non-dangerous 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 – Large psychiatric hospitals closed
Transinstitutionalization – Mentally ill to community care
Liberal Changes in Civil Commitment Procedures Followed

7. Britain Bedlam

8. Subsequent Modification to Civil Commitment Procedures
Civil Commitment Criteria Were Broadened
Involuntary commitment
For dangerous and non-dangerous persons
For persons in need of treatment
National Alliance of the Mentally Ill
Argued for further reforms

9. Criminal Commitment: An Overview
Nature of Criminal Commitment
Accused of committing a crime
Detainment in a mental health facility for evaluation
Focus on fitness to stand trial
Found guilty or not guilty by reason of insanity

10. The Insanity Defense
Nature of the Insanity Defense Plea – A Legal Statement
Accused of not guilty because of insanity at time of crime
Defendant sent to a treatment facility rather than prison
Diagnosis of a disorder is not the same as insanity
Definitions of Insanity
M’Naughten rule – Insanity defense originated here
Durham rule – More inclusive definition
Mental disease or defect
American Law Institute Standard
Knowledge of right vs. wrong
Self-control
Diminished capacity

11. Consequences of the Insanity Defense
Public Misperceptions and Outrage
John Hinckley Jr. found not guilty by reason of insanity
50% of states – Moved to abolish the insanity defense
Public views – Insanity defense is a legal loophole
Facts About the Insanity Defense
Used 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
Movement back to M’Naughten-like standards
Guilty but mentally ill (GBMI)
Allows for treatment and punishment

12. Therapeutic Jurisprudence
Overview
Using knowledge of behavior change
To help those in trouble with the law
“Problem Solving” Courts
Address unique needs of people with specific problems
Examples include delayed sentencing under the condition the individual holds a job for six months

13. 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

14. The Role of Expert Witness in Civil and Criminal Proceedings
The Expert Witness: Psychologists’ Roles
Person with specialized knowledge and expertise
Assist in competency determinations
Assist in making reliable DSM diagnoses
Advise the court
Regarding psychological assessment and diagnosis
Assess malingering (i.e., faking symptoms)

15. Patient’s Rights: An Overview
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
The Right to Confidentiality vs. Duty to Warn
Confidentiality – Protect disclosure of information
Tarasoff and the Duty to Warn – Limits on confidentiality

16. 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
Right to Anonymity in Report of Study Findings
Right to Safeguarding of Records

17. Clinical Practice Guidelines and Standards
Agency for Health Care Policy and Research
Efficient and cost-effective mental health services
Dissemination of relevant state-of-the-art information
To practitioners and the general public
Establish clinical practice guidelines
For assessment and treatment
American Psychological Association’s Practice Guidelines
Standards for clinical efficacy research
Standards for clinical utility (effectiveness) research

18. Summary of Ethical and Legal Issues in Mental Health Services
Societal Views and Laws About Mental Illness
Have changed over time
Mental Illness Is a Legal Term, Not a Psychological Term
Civil Commitment Is a Legal Processes
Involves involuntary commitment
Criminal Commitment
Involves criminal behavior and mental illness
Involves competence, insanity, and criminal culpability
Role of Mental Health Professionals in Legal Matters
Rights of Patients and Research Subjects
The Future of Mental Health Care