Mental Health Services and Society

1
Mental Health Services Legal and
Ethical Issues
2
An Overview of the Issues

• Can and should we commit persons to psychiatric
  hospitals against their will?

• Do involuntarily committed patients have the
  right to refuse treatment?

• Is mental illness a reasonable excuse for
  committing a criminal offense?

• What is ethical or legal practice? Are they the
  same? and, how to decide?

3
Mental Health and the Law

• Defining Mental Illness
• Mental Illness is a Legal Concept
• Varies by State
• Not the Same as Psychological Disorder

4
Mental Health and the Law
Civil Commitment

• Civil Commitment Laws
• Legal Declaration of Mental Illness
• Hospitalization for Treatment

• Criteria for Civil Commitment
• Person has a Mental Illness
• Needs Treatment
• Is Dangerous (self or others)
• Is Unable to Care for Self

5
Mental Health and the Law
Civil Commitment

• Governmental Justification
• Protection of Public Safety Welfare
• Exercises Police Power
• Exercises Parens Patriae

6
Mental Health and the Law
Civil Commitment

• Changes Affecting Civil Commitment
• Supreme Court Ruling

• Consequences of Changes
• Criminalization of Mentally Ill
• Deinstitutionalization
• Homelessness

7
The 1960s and Deinstitutionalization

• Mental Illness is No Longer Enough
• Massive Discharge of Patients
• From 560,000 Hospitalized in 1955
• To lt 100,000 Hospitalized Today
• Greyhound Therapy

• Many Psychiatric Hospitals Closed
• BUT, Did it Work?

8
Mental Health and the Law
Criminal Commitment

• The Issues
• If Someone Commits a Crime While Mentally Ill,
  are They Responsible?
• If Someone is Mentally Ill now, but NOT at the
  Time of the Crime, Should They be Brought to
  Court?
• If Someone was Mentally Ill at the Time of the
  Crime, BUT Appears Fine Now, Should They be Held
  Accountable?

9
Mental Health and the Law
Criminal Commitment

• Processes Involved
• Accused of Committing a Crime
• Detained in a Mental Health Facility
• Assessed for Fitness or Unfitness to Stand Trial
  OR
• Found not Guilty by Reason of Insanity

10
Mental Health and the Law
Criminal Commitment

• The Insanity Defense
• MNaughten Standard
• Durham Rule
• American Law Institute Standard
• Diminished Capacity
• Insanity Defense Reform Act

11
Mental Health and the Law
Criminal Commitment

• How Often is the Insanity Defense Used?
• Less Than 1 of All Cases!
• Of those 1, many spend more time hospitalized
  than they would have in jail

12
Mental Health and the Law
Assessing Competence

• The Person Must
• Understand the Charges Against Them
• Be Able to Assist in Own Defense
• Incompetence Usually Results in Involuntary
  Commitment
• Requires Judgement of Expert Witnesses

13
Mental Health and the Law
Professional Responsibilities

• Tarasoff v. Regents of U. California
• The Result?
• Duty to Warn
• Functioning as Expert Witness
• Court Still Makes MI Judgement
• Assess Competence Malingering
• Assess Dangerousness, etc.

14
Mental Health and the Law
Clinical Practice Guidelines

• Agency for Health Care Policy Research
• FDA of Effective Treatment Delivery
• Clinical Practice Guidelines for Disorders
• APA Task Force Followed Suit
• Clinical Effectiveness v. Efficacy

15

• Treatment Worked
• 87 Improved
• Long Term Treatment Better than Short-Term
• Therapy vs. Therapy Plus Meds Were Similar
• Limit Care Poor Outcome

Duration of Therapy
Consumer Reports Magazine
16
Mental Health and the Law
Patient Rights

• Patients Have the Right to
• Treatment
• Refuse Treatment
• Point to Ponder
• Can people be forced to become competent to
  stand trial?

17
Changing Face of Mental Health Care

• More Scientifically Driven Treatments
• More Manualized Treatments
• Fewer Psychologists Providing Treatment
• Briefer Therapies Cost Containment
• Fewer Hospitalizations
• Greater Use of Medications