American Psychiatric Association. Guideline for legislation on the psychiatric hospitalization of adults

"The incarceration revolution": the abandonment of the seriously mentally ill to our jails and prisons

It is well known that today jails and prisons house many seriously mentally ill citizens who in prior decades have been treated in mental hospitals and community mental health programs. This paper begins with a brief review of the history of support for mental health programs at the federal level and then, using the State of Oregon as an example, describes the new state era of mental health services which is characterized by the increasing use of the criminal justice system as a cornerstone of the treatment of many seriously and chronically mentally ill individuals. Are there any solutions to our current dilemma? The paper ends with this question, and the reader must determine if any of the suggestions posed in this discussion are realistic and/or feasible given the current fiscal and political climate.

The state of contemporary risk assessment research

The focus on assessing dangerousness in routine psychiatric practice developed when relatively little was known about factors related to violence, and the accuracy of predicting violence was distinctly below chance. Since the 1990s, however, significant research attention has been directed toward factors related to violence and mental illness, as well as toward factors related to the accuracy of risk assessment techniques. Sociodemographic and environmental variables have been identified as significant predictors of violence, as has the presence of substance abuse. However, the data on specific mental health variables are somewhat mixed. Many studies point to a modest increased risk of violence associated with major mental illness and psychosis, whereas other noteworthy studies have failed to confirm such findings. Studies of the accuracy of risk assessments indicate that both actuarial and clinical methodologies perform better than chance, although the former achieve greater statistical accuracy. Despite ongoing controversies, risk management strategies that encompass the strengths and limitations of our present knowledge are available to clinicians.

Criteria for involuntary hospitalisation

OBJECTIVE

The aim of this paper is to provide an overview of the ethical bases of compulsory commitment legislation.

METHOD

The ethical principles of beneficence and autonomy are examined and used to identify criteria for the commitment of mentally ill patients.

RESULTS

Two aspects of beneficence, medical paternalism and social paternalism, are discussed. It is argued that social paternalism is insufficient ethically to warrant involuntary admission, and that the basis for compulsory hospitalisation is medical paternalism.

CONCLUSION

The central role of autonomy in medical ethics suggests a patient should have a diminished capacity for autonomous decision-making and a potential to benefit from hospitalisation, as well as a risk of harm to self (including self-neglect) to warrant committal. In specific circumstances, the risk of harm to others may also justify committal. These ethical principles may be at odds with public attitudes.

Treatment of suicidal patients: a risk-benefit analysis

A therapist may be held liable when a patient commits suicide if previous suicidal tendencies were observed but reasonable precautions were not taken. In order to reduce liability and enhance treatment effectiveness, therapeutic decisions can be critiqued by estimating the risks and benefits associated with different courses of action. An evaluation of risks and benefits can be used to guide decisions regarding assessment, hospitalization, medications, and discharge from the hospital. A risk-benefit analysis can help therapists utilize a broad range of treatment options while allowing patients the maximum degree of autonomy. Additionally, all aspects of treatment should be well documented, including information about the specific course of action chosen, other treatment options considered, and the therapeutic rationale for deciding which treatment plan was best suited to the patient's needs.

The dangerousness criterion for civil commitment: the problem and a possible solution

The dangerousness criterion for civil commitment fails to specify which mental disorders justify commitment. This ambiguity is highlighted by the fact that there are patients with personality disorders or substance abuse who may be dangerous but for whom we have few effective treatments. A possible solution might be provided by adopting the American Psychiatric Association guidelines which consider severity of mental disorder and treatability in its criteria.

Belegaled: mental health and the law in the United States, 1986

Kenneth Gray, an attorney as well as a psychiatrist, was the leader in the development of law and psychiatry in Canada prior to his death in 1970. He lived during the post WWII years which saw a phenomenal growth of psychiatry as well as the beginnings of the modern era of a renewed concern for human rights. This later concern has caused the belegalment of many areas of psychiatric practice. Kenneth Gray would have to learn a new set of rules for commitment, the use of ECT and informed consent. He would discover that a patient has a right to treatment that must be buttressed by an individual treatment plan. He would discover that a committed patient has a right to refuse treatment and that some courts in the United States have said that anti-psychotic medications are mind-altering and thus an invasion of the patients 1st amendment rights. He would see untreated refusing patients languishing in the hospital or the homeless mentally ill on the streets because of restrictive commitment laws. As an attorney he would also be concerned about the proposed solution to the homeless, outpatient commitment. He certainly would have been impressed with some of the recent decisions in the United States on our duty to warn or protect known and unknown victims. Seeing patients' advocates on the hospital wards would be a real surprise to him. These controls on the practice of psychiatry for the protection of our patients cut both ways. Dr. Gray's medical/legal education would be tested to its full.