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Chapter 16.pdf

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Psychology 2030A/B
David Vollick

Abnormal  Psychology  Chapter  16:   Mental  Health  Services:  Legal  and  Ethical  Issues     Introduction   • As  public  opinion  of  people  with  mental  illness  changes,  so  do  the  laws   affecting  them,  and  legal  and  ethical  issues  have  an  effect  on  both  research   and  practice   • The  issues  affecting  research  and  practice  are  often  complementary     Civil  Commitment   • Laws  have  been  designed  to  protect  people  who  display  abnormal  behaviour   and  to  protect  society   • Each  province  and  territory  has  civil  commitment  laws  under  the  provincial   or  territorial  Mental  Health  Acts  that  detail  when  a  person  can  be  legally   detained  in  a  psychiatric  institution  –  even  against  his  or  her  will     Criteria  for  Civil  Commitment   • Although  there  is  variability  across  provinces  and  territories   • Most  provincial  legislation  permits  commitment  when  the  following  three   conditions  have  been  met:   1. The  person  has  a  mental  disorder   2. The  person  is  dangerous  to  himself  or  herself  or  others   3. The  person  is  in  need  of  treatment   • All  Canadian  jurisdictions  require  the  first  and  third   • Although  every  Canadian  jurisdiction  but  one  (Quebec)  requires  that  a  person   have  a  mental  illness  before  he  or  she  can  be  detained  under  civil  commitment   legislation,  the  definition  of  “mental  illness”  differs  across  jurisdictions   • Although  every  Canadian  jurisdiction  also  requires  that  a  person  be  a  danger   to  himself  or  herself  or  others,  or  that  the  person  needs  to  be  hospitalized  for   his  or  her  safety  or  protection  or  for  the  safety  or  protection  of  others,  the   provinces  and  territories  vary  considerably  in  how  they  define  “safety”  and   “protection”   • The  Canadian  jurisdictions  also  differ  on  several  other  issues  pertaining  to   civil  commitment,  such  as  whether  the  patient  has  the  right  to  refuse   treatment,  the  right  to  be  informed  of  the  reasons  for  the  hospital  detention,   the  right  to  apply  to  a  review  panel  that  can  grant  a  discharge  from  the   hospital,  and  the  specified  right  to  legal  counsel   • These  safe  guards  are  built  into  the  person  being  examined  and  to  ensure  that   no  one  is  involuntarily  committed  to  a  psychiatric  facility  for  other  than   legitimate  reasons   • That  the  government  justifies  its  right  to  act  against  the  wishes  of  an   individual  under  two  types  of  authorities:  police  power  and  parens  patriae   power   • Under  police  power,  the  government  takes  responsibility  for  protecting  the   public  health,  safety,  and  welfare  and  can  create  laws  and  regulations  to   ensure  his  protection   • Provinces  and  territories  apply  parens  patriae  power  in  circumstances  I   which  citizens  are  not  likely  to  act  in  their  own  best  interest   • Under  parens  patriae  power,  the  government  acts  as  a  surrogate  parent,   presumably  in  the  best  interests  of  a  person  who  needs  help   • A  person  in  need  of  help  can  always  voluntarily  request  admission  to  a  mental   health  facility;  after  an  evaluation  by  a  mental  health  professional,  he  or  she   may  be  accepted  for  treatment   • When  an  individual  does  not  voluntarily  seek  help,  but  others  feel  that   treatment  or  protection  is  necessary,  the  process  of  civil  commitment  may  be   initiated   • Typically  one  or  two  physicians  or  psychiatrists  must  conduct  an  assessment   and  agree  that  the  person  meets  the  criteria  for  commitment  outlined  in  the   relevant  jurisdictions  legislation   • In  Canada,  people  deemed  suitable  for  commitment  are  not  necessarily   committed  to  a  hospital   • Instead,  there  are  also  options  for  compulsory  community  treatments  (CCT)   for  the  mentally  ill   • CCT’s  main  goals  are  to  prevent  relapse,  and  to  provide  care  in  a  less   restrictive  environment   • CCT  is  not  permitted  in  Canada  until  there  has  already  been  previous   inpatient  treatment   • The  necessary  criteria  for  CCT  in  Canadian  jurisdictions  are  that  the  patient   must  have  some  risk  of  increased  mental  deterioration,  or  possibly  pose  harm   to  him  or  herself  or  others     Defining  Mental  Illness   • Mental  illness  is  a  legal  concept,  typically  meaning  severe  emotional  or   thought  disturbances  that  negatively  affect  an  individuals  health  and  safety   • Functional  definition  specifies  the  effect  of  the  illness  on  the  patients  thoughts   and  behaviour   • Mental  illness  is  not  synonymous  with  psychological  disorder;  in  other  words,   receiving  a  DSM  diagnosis  does  not  necessarily  mean  that  a  person  fits  the   legal  definition  of  someone  having  a  mental  illness   • Ambiguity  allows  for  flexibility  in  making  decisions  about  individual  cases,  but   it  also  creates  the  possibility  of  subjective  impression  and  bias  influencing   these  decisions     Dangerousness   • Assessing  whether  someone  is  a  danger  to  himself,  herself,  or  others  is  a   critical  determinant  of  the  civil  commitment  process   • Dangerousness  is  a  particularly  controversial  concept  for  people  with  mental   illnesses:  popular  opinion  tends  to  be  that  people  who  have  a  mental  illness   are  more  dangerous  than  those  who  do  not   • The  results  of  research  on  dangerousness  and  mental  illness  are  mixed   • Fraser  showed  a  link  between  risk  for  violence  and  certain  forms  of  mental   illness  –  specifically  psychotic  disorders   • Thus,  major  mental  illnesses  such  as  bipolar  disorder  and  schizophrenia  do   seem  to  elevate  the  odds  of  violence  in  comparison  with  other  mental   disorder  and  in  comparison  with  individuals  with  no  mental  disorder   • Douglas  and  Hart  found  that  the  psychotic  symptoms  of  delusions  and   hallucinations  were  particularly  strongly  related  to  risk  for  violence   • The  widely  held  misperception  that  people  with  mental  illness  in  general  are   more  dangerous  may  differentially  affect  ethnic  minorities  and  women   • Recent  research  has  shown  that  accurate  predictions  of  the  risk  for  violence   are  indeed  possible   • The  job  of  assessing  patients  risk  for  suicide  and  other  self-­‐harm  is  an   important  and  common  activity  for  many  mental  health  professionals   • Found  that  those  patients  who  reported  suicidal  thought  while  in  the  hospital,   those  who  showed  verbal  and  physical  aggression  toward  others  in  the   hospital,  those  with  a  history  of  self  harm,  and  those  engaged  in  a  suicide   attempt  or  other  form  of  self-­‐injurious  behaviour  within  the  two  weeks  before   being  committed  to  hospital  were  most  likely  to  harm  themselves  while  in   hospital   • Scale  called  the  Suicide  Risk  Assessment  Scale  (SRAS)  for  prisoners  was   developed  by  a  group  of  researchers  at  the  correctional  service  of  Canada     Deinstitutionalization  and  Homelessness   • Two  trends  have  influenced  the  number  of  people  in  Canada  who  are   involuntarily  committed  each  year:   1. The  increase  in  the  number  of  people  who  were  homeless   2. Deinstitutionalization,  the  movement  of  people  with  severe  mental   illness  out  of  institutions   3. Homelessness,  although  not  exclusively  a  problem  of  the  mentally  ill,  is   largely  determined  by  social  views  of  people  with  mental  illness   • There  are  many  younger  people,  women,  and  families  living  on  the  streets   • First  Nations  people,  refugees,  and  ethnic  minorities  are  over-­‐represented   among  the  Canadian  homeless   • The  limits  placed  on  the  stays  of  people  with  severe  mental  illness,  and  the   concurrent  closing  of  large  psychiatric  hospitals  were  held  responsible  for  the   substantial  increase  in  homelessness   • The  rise  in  homelessness  is  also  due  to  such  economic  factors  as  increased   unemployment  and  a  shortage  of  low  income  housing   • Deinstitutionalization  is  one  factor  that  many  believe  has  contributed  to   increasing  rates  of  homelessness  in  Canada   • Deinstitutionalization  had  two  goals:   1. To  downsize  or  even  close  the  large  provincial  and  territorial  mental   hospitals   2. To  create  a  network  of  community  mental  health  services  in  which  the   released  individuals  could  be  treated   • The  first  goal  of  the  deinstitutionalization  movement  appears  to  have  been   substantially  accomplished   • However,  the  second  goal  of  providing  alternative  community  care  has  not   • Instead,  there  was  transinstitutionalization,  or  the  movement  of  people  with   severe  mental  illness  form  large  psychiatric  hospitals  to  nursing  homes  or   other  group  residences,  including  jails  and  prisons,  many  of  which  provide   only  marginal  services   • Because  of  the  deterioration  in  care  for  many  people  who  had  previously  been   served  by  the  provincial  or  territorial  mental  hospital  system,   deinstitutionalization  is  largely  considered  a  failure       Criminal  Commitment   • Battered  woman  syndrome  is  not  recognized  in  the  DSM   • The  term  refers  to  a  state  of  learned  helplessness  or  post-­‐traumatic  stress  that   results  from  chronic  abuse  within  a  relationship  such  that  a  woman  feels   unable  to  leave   • Mock  jurors  were  more  likely  to  find  the  defendant  guilty  of  murder  if  the   spouse  was  asleep  than  is  the  death  occurred  during  a  fight   • Harsher  verdicts  evidenced  in  the  nonimminent  threat  condition  were  more   pronounced  when  no  expert  testimony   • Thus,  expert  testimony  appears  beneficial  to  victims  of  abuse  in  cases  like  that   • Criminal  commitment  is  the  process  by  which  people  are  held  because   1. They  have  been  accused  of  committing  a  crime  and  are  detained  in  a   mental  health  facility  until  they  can  be  assessed  as  fit  or  unfit  t   participate  in  legal  proceedings  against  them   2. They  have  been  found  not  criminally  responsible  on  account  of  a   mental  disorder  (NCRMD)     The  Insanity  Defense   • The  law  recognizes  that,  under  certain  circumstances,  people  are  not   responsible  for  their  behaviour  and  it  would  be  unfair  and  perhaps  ineffective   to  punish  them   • In  what  has  become  known  as  the  M’Naghten  rule,  the  English  court  decreed   that  people  are  not  responsible  for  their  criminal  behaviour  if  they  do  not   know  what  they  are  doing  or  if  they  don’t  know  that  what  they  are  doing  is   wrong   • The  M’Naghten  rule  was  the  most  common  insanity  defense  used  in  the  last   half  of  the  19  century  and  well  into  the  20  century   • Concerns  were  raised  about  whether  patients  detained  under  criminal   commitment  were  actually  receiving  sufficient  treatment   • Concerns  were  also  expressed  that  the  detention  periods  in  psychiatric   facilities  were  often  much  longer  than  the  prison  sentence  the  person  would   have  served  if  he  or  she  had  been  convicted  of  the  offence   • The  name  of  the  defense  was  changed  form  not  guilty  by  reason  of  insanity   (NGRI)  to  not  criminally  responsible  on  account  of  mental  disorder  (NCRMD)   • There  are  three  main  difference  between  the  NGRI  and  the  NCRMD  defenses   1. The  term  “insanity”  has  been  replaced  by  “mental  disorder”   2. The  defendant  is  now  considered  “not  criminally  responsible”  as   opposed  to  “not  guilty”   3. The  meaning  of  “wrong”  has  changed  form  NGRI  to  NCRMD   • Unlike  NGRI,  which  was  concerned  only  with  legal  wrongs,  NCRMD  judgments   can  be  made  if  the  person  is  incapable  of  knowing  that  his  or  her  actions  were   either  legally  or  morally  wrong     Reactions  to  the  Insanity  Defense   • Research  supports  that  the  public  often  holds  negative  perceptions  about  the   NCRMD  defense   • Although  the  NCRMD  defense  is  used  more  often  that  the  old  NGRI  defense,  its   use  is  still  relatively  uncommon   • Findings  show  that  although  the  use  of  this  never  defense  is  increasing,  it  is   still  fairly  uncommon   • Although  the  NCRMD  defense  does  not  entail  automatic  detention  in  a   psychiatric  hospital,  some  defendants  end  up  being  incarcerated  in  psychiatric   institutions  for  much  longer  periods  than  they  would  have  been  sentenced  to   prison  if  they  had  n
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