Lecture 14
Mental Health Services and Society:
Legal, Ethical, and Professional Issues Affecting Research and Practice
Dale L. Johnson
Legal and
Ethical Issues
This lecture will be fairly brief although
the topic itself is not at all brief. Legal issues virtually define psychiatric
practice today, and that means that psychiatrists, psychologists, social
workers, psychiatric nurses and all who work in the field must be aware of
legal issues in their work everyday. For those who might have a special
interest in the topic and are looking for a quick overview I can recommend
Sales, B. D., & Shuman, D, W. (1996). Law, mental health, and mental
disorder. Pacific Grove, CA: Brooks Cole.
In the USA treatment of people with
mental illness is in crisis. We provide the poorest treatment of any developed
country because as a nation we do not have a mental health policy, a commitment
to provide care for those in need, and a system that is underfunded and fragmented.
We are the only country that treats mental illnesses differently than physical
disorders. There has been a legislative campaign led by Senators Pete Domenici
(New Mexico) and Paul Wellstone (deceased)(Minnesota) to assure parity in
insurance coverage. This means that people with mental illness would have
health insurance coverage that is the same as people with physical illnesses.
Even though one of the primary sponsors, Senator Domenici, is a republican,
members of the republican party have blocked passage of the bill in the past.
Now, President Bush says he will support passage and maybe it will pass in 2003
(But Congress has not acted as of November)..
As important as parity legislation
is it still would not provide coverage for the 44 million Americans who do not
have health insurance. Again, we are the only nation with out a health plan
that covers all citizens. Such a plan was blocked by the American Medical
Association when it was proposed by President Truman in 1952 and by President
Nixon in 1973. It was blocked by the managed care and insurance companies when
proposed by President Clinton in 1992. Today, most physicians favor a universal
coverage plan because they are disgusted with the current health care mess.
People with mental illness are badly
treated by the current system. In Texas the money available for community
mental health centers and state/county hospitals from state funds and Medicaid
(federal) has never been much. Texas typically ranks about 49th in per capita
spending on mental health. However, with the managed care addition brought to
Texas by Governor Bush these funds were cut in half. 50% of these funds go for
management. In 2000 the CEO of United Health Care Group received $54.1 million.
One person. This is more than the entire mental health budgets of Alaska,
Delaware, Idaho, New Mexico, North Dakota, South Dakota, Vermont, West Virginia
and Wyoming (nine states).
We need a single payer, universal
coverage health system if we are to improve care for all Americans including
those with mental illness. Many politicians are afraid to take a position for
such a plan because they think most Americans are opposed. Many Americans are
opposed because they believe that
a) A single payer system similar to
the one in Canada would cost more than our present system.
Truth: it would cost less. We
already pay more for health care out of the public sector (military, VA, Indian
Health Service, Medicare, Medicaid, Seamans services) than any other country in
the world.
b) Doctors will not accept it.
Truth. Most physicians and
medical students are in favor of a single payer system.
c) In Canada doctors and nurses have
left the country for the USA in droves because they cannot stand the system
Truth. A few Canadian doctors
and other medical specialist have left the country, but so have quite a few
American doctors and medical specialists. Some people just move around. I have
been in Canada many times since they began their health plan and have talked
with many Canadian doctors. They like their system. As one pediatrician who was
doing his residency at Baylor told me: "I can't wait to get home so I can
practice medicine and not spend my time filing out forms and explaining my
procedures to managed care idiots."
d) It would be too difficult to
change the present system.
Truth. It would be easy. All
that would be necessary would be to extend Medicare to everyone, not just those
who are elderly. We could eliminate the VA, Indian Health Service, Military,
etc. Federal taxes would go up, but neither we nor our employers would have to
pay insurance premiums. Bill Gates and the child down the street from me who
has no parents would have the same coverage.
e) We can never persuade the
congress to act.
Maybe. States are taking the
initiative. We in New Mexico came close to having a single payer system two
years ago. Maine is close now. What is happening is that towns and cities are
passing resolutions calling for legislators to act. This is a powerful
procedure. It is a little hard to imagine it happening in Houston, but I could
not rule it out. There are an awful lot of people in the Harris County who do
not have access to health care and a lot more who have some insurance, but
cannot afford quality treatment.
NAMI
In 1979 two women in Madison,
Wisconsin, were having coffee together one morning. Both had sons with
schizophrenia and both were angry and frustrated about the services their sons
were receiving. They agreed that families of people with serious mental illness
should be heard and come up with the idea of starting a national organization
of families. They made phone calls and organized a conference. The National
Alliance for the Mentally Ill, now called NAMI, was formed and today it has
spread to all 50 states and Puerto Rico and territories and district), and has
more than 200,000 members. Local groups have mutual support groups and provide
education to the members and they join the state and national groups in
advocacy. My regard for the organization may be measured by the fact that I was
president of the national NAMI one year and was on the board seven years. In
his review of three recent books about the state of psychiatric services in the
USA Arthur Kleinman, Harvard psychiatrist, deplored much about modern
psychiatry and said, "...arguably the most important development in the
mental health field has been the organization of the mentally ill, their
families and supporters into an effective political force. They have fought
stigma with improved knowledge and awareness, and have successfully lobbied for
more research funding, better health insurance coverage and more effective treatment
and rehabilitation oprograms."
In testimony before the Legislative
Budget Borad and Governor's office (9/10/2002) Diane Bigg, Exectutive Director
of NAMI-Texas had the following to say:
150,000 adults and children with
serious mental illness are being treated in the Texas mental health system.
150,000 adults and children who were
in the Texas mental health system are now in the prisons, jails or on probation
or parole.
40,000 Texans receive inadequate
treatment and rehaiblitation.
She asked for an increase in funding
and for a new state mental health plan and a more equitable distribution of
state funds (now Harris county, the most populous county receives less than
half of the amount received in Deaf Smith county on a per capita basis). Previous pleas have gone unanswered.
Criminal
Commitment: people who are accused of commiting a crime
and are held in a mental health facility to determine whether they are fit to
understand the legal procedings ahead of them. Harris County jail has beds for
279 such prisoners. The LA County jail is the largest single mental health
hospital in the world. In all of these jails prisoners wait for long periods
often with mimimal treatment.
NM Jails Blue
Ribbon Commission.
Several years ago I was asked by the
governor of New Mexico, Gary Johnson (no relation even though our fathers were
from the same small town in North Dakota) to serve on a commission to make
recommendations regarding suicide risk in state jails and prisons. The
commission was made up of legislators, judges, psychiatrists, jailers, and
others who knew something about the state penal system. We met many times, at
our own expense, and made three recommendations:
1.
screen for mental illness and suicidal ideas.
2.
provide social workers to refer identified prisoners out to appropriate
residences.
3.
provide funds to develop residential placements.
We also pointed out that training of
jailers was essential, but could be done at no cost to the sate through federal
programs already functioning in other states.
We had determined that our
recommendations would save lives, would cost very little, and were in effect in
most other states. The state legislature approved our recommendations and sent
the bills on to the governor. He vetoed them without explanation. I asked the
governor why he had vetoed the bills. He seemed vague about what it was that he
had vetoed, but said they would cost to much. Apparently, insurance companies
believed the acts would reduce their earnings and they lobbied the governor to
veto. Politics everywhere. Actually, insurance companies that covered city and
county jails would have had lower costs with the legislation.
________________________________________________________________________
Right to
Refuse Treatment
One of the most controversial legal
issues involving people with mental illness is the question of whether a mentally
ill person should be forced to accept treatment. Remember that people with
psychotic disorders, and this means most people with schizophrenia or bipolar
disorder in acute conditions, and some people with severe depression, do not
realize that they are ill and typically refuse treatment.
Psychosocial
Rehabilitation Journal,
1998, 21,
252-254.
The Right To Refuse Medication: Freedom
and Responsibility
Dale L. Johnson
University of Houston
The preservation of individual
freedoms is basic to the American way of life. These freedoms are wide-ranging
and extend to what we eat or drink and which medicines we take. Freedoms are
expected as a part of normal adult life, but society does not hesitate to act
for children or adults of low intelligence or even for elderly adults with
dementia. It is assumed that these people are not competent to make all
decisions for themselves. Individuals who have become psychotic also may lose freedoms, and it is for this group that
problems of definition arise. Many, perhaps most, of these people are able to
recognize that they might benefit from medical treatment and comply willingly.
They are able to take responsibility for managing their illness. Others, owing
to the form of their illness, deny a need for treatment, do not accept that
they have an illness, and do not comply with prescribed medications. Because of
the illness they are not able to act responsibly.
Acceptance
of medication is a complex mixture of at least four elements: The person must
have 1) an understanding of the prescribed medication, 2) an understanding of
the self, 3) an understanding of the illness, and 4) an ability to trust the
person who has prescribed the medication. People stop taking antibiotics and
other medications prematurely, usually because they do not have an adequate
understanding of how the medications work. The other three criteria do not come
into play. However, it is the essence of serious mental illnesses when
accompanied by psychosis that there is an impairment of judgment and decision-making
capacity and all four of the requirements may be impaired. The workings of the
medication are not understood, the role of the self in making a decision is
unclear (e.g., not being aware of changes in one’s personal normative
behaviors), the illness is denied, and there may be a lack of trust in other
people.
What happens
to people who are not treated?
The use of medication in the
treatment is so well-accepted by mental health professionals that it is now considered
unethical not to use medication if its use appears to be warranted by the
person’s mental condition (McGlashan & Johannessen, 1996). In general, people who have been judged to
need medication as part of a treatment plan and who reject this treatment have
poorer clinical outcomes and more difficulties in the course of treatment than
those patients who accept medication (Littrell et al., 1994; Wyatt et al.,
1997). Furthermore, there is mounting evidence that failure to treat early
results in a generally worsening condition (McGlashan & Johannessen, 1996).
Refusal
to take prescribed medication has been found to be a major cause of commitment
and rehospitalization. Medication refusers were also found to be more
aggressive (Smith, 1989). In his review of research on violence and serious
mental illness, Torrey (1994) found: “The data .. suggest that individuals with
serious mental illnesses are not more dangerous than the general population
when they are taking their antipsychotic medication. When they are not taking
their medication, the existing data suggest that some of them are more
dangerous.” (P. 659).
Second
Thoughts on Medication Refusal
Perhaps the strongest argument for
compelling medication treatment stems from research that has shown that most
patients, after alleviation of symptoms with treatment, agree that medication treatment was right
for them. For example, Kane et al (1983) followed a group of patients who had
been involuntarily committed to a state hospital. When asked if the forced treatment
had been “fortunate” 69% agreed that it had been. Furthermore, their attitudes
were supported by their behavior: 64% accepted out-patient treatment and of the
group that had relapses, 93% were readmitted voluntarily. In another study,
Gove and Fain (1977) interviewed patients after hospitalization. Of the
involuntarily hospitalized group, 75% thought hospitalization had been helpful.
Of the voluntarily admitted group, 80% thought the hospitalization had been
helpful. Other studies have found much the same thing.
Another
consequence of refusing medication is that a continuing psychotic state
increases dependence on others. People with untreated psychoses have difficulty
taking care of themselves. Many must rely on others, usually near relatives, to
care for them, and this results in a substantial financial and emotional burden
for the relatives.
Alternatives
to Coercion
Pointing out the adverse
consequences of medication refusal is not enough. Humane treatment requires
that every step be taken to eliminate the need for coercive treatment by using
available alternatives.
More
Acceptable Medications
One
of the main arguments for not taking medications is that the side effects seem
worse than the condition they are designed to treat. New medications, the atypical antipsychotics such as clozapine,
risperidone and olonzapine, have fewer side effects than typical antipsychotic
medications. Distressing extrapyramidal side effects, including akathisia, are
less likely to occur. (Owens, 1994; Tollefson et al., 1997). Perhaps no
medications will be lacking in unpleasant side effects for some patients, but
given than the new atypical medications are more tolerable, one of the major
objections to medication is minimized.
Medication
Education
If consumers understand the purpose
of medications and know of how they function they are more likely to take them
as prescribed. Several ways of providing medication education have been
developed. A single instructional session has been found to have some
educational benefits (Kleinman et al., 1993). Cognitive behavioral
psychotherapy has been used effectively (LeCompte & Pelc, 1996). However,
in order to have a substantial impact on medication compliance more extensive
and intensive methods are necessary. Eckman et al., have developed such methods
and have shown that with this training patients are more likely to take
prescribed medications and to accept their illness.
Conclusions
If
there is reason to believe that a medication is available that will provide
positive benefits to people with this particular illness, and if there is
reason to believe that the person will not suffer an adverse reaction to the
medication, and if on careful examination by more than one competent mental
health professional it is found that the person is not capable of deciding in
his or her own
best interest,
then medication should be given, even if administration requires force. The
risk to the ill individual and to society is too great to do otherwise.
However, this step should not be taken until the person is provided with
information needed to make a decision and in a form that is acceptable and
understandable. Freedoms are always balanced by responsibilities. Freedoms must
be guarded and the ability to act responsibly must be fostered.
References
Eckman,
T. A., Liberman, R. P., Phipps, C. C., & Blair, K. E. (1990). Teaching
medication management skills to schizophrenic patients. Journal of Clinical
Psychopharmacology, 10, 33-38.
Gove,
W. R., & Fain, T. (1977). A comparison of voluntary and committed
psychiatric patients. Archives of General Psychiatry, 34, 669-676.
Kane,
J. R., Quitkin, F., Rifkin, A., Wegner, J., Rosenberg, G., & Borenstein, M.
(1983). Attitudinal changes of involuntarily committed patients following
treatment. Archives of General Psychiatry, 40, 374-377.
Kleinman,
I., Schachter, D., Jeffries, J., & Goldhamer, P. (1993). Effectiveness of
two methods for informing schizophrenic patients about neuroleptic medication. Hospital
and Community Psychiatry, 44, 11-89-1191.
LeCompte,
D., & Pelc, C. (1996). A cognitive-behavioral program to improve compliance
with medication in patients with schizophrenia. International Journal of
Mental Health, 25, 51-56.
Littrell,
R. A., Mainous, A. G., Karem, F., Coyle, W. R., & Reynolds, C. M. (1994).
Clinical sequelae of overt noncompliance with psychotropic agents. Psychopharmacology
Bulletin, 30, 239-243.
McGlashan,
T. H., & Johannessen, J. O. (1996). Early detection and intervention with
schizophrenia: rationale. Schizophrenia Bulletin, 22, 201-222.
Owens,
D. G. C. (1994). Extrapyramidal side effects and tolerability of risperidone: a
review. Journal of Clinical Psychiatry, 55, 29-35.
Smith,
L. D. (1989). Medication refusal and the rehospitalized mentally ill inmate. Hospital
and Community Psychiatry, 40, 491-496.
Tollefson,
G. D., Beasley, C. M., Tran, P. V., Street, J. S., Krueger, J. A., Tamura, R.
N., Graffeo, K. A., & Thieme, M. E. (1997). Olanzapine versus haloperidol
in the treatment of schizophrenia and schizoaffective and schizophreniform disorders:
Results of an International Collaborative Trial. American Journal of
Psychiatry, 154, 457-465.
Torrey,
E. F. (1994). Violent behavior by individuals with serious mental illness.
Hospital and Community Psychiatry, 45, 653-662
Wyatt,
R. J., Green, M. F., & Tuma, A. H. (1997). Long-term morbidity associated
with delayed treatment of first episode schizophrenic patients: A re-analysis
of the Camarillo State Hospital data. Psychological Medicine, 27,
261-268.
________________________________________________________________________
Two states, New York and
California, have acted on the right to
refuse treatment with laws that require forced treatment. In New York this is known
as Kendra's Law and in California it is Laura's Law. Laura Wilcox was a
19-year-old high school valedictorian who was killed by a psychotic man who had
refused treatment. The laws are for outpatient commitment to assure that
treatment recommendations will be followed. If they are not the person is
placed in a hospital. The laws can only be activated if family (if they can be
located) and mental health professionals favor action. My contention in the
article above that people should have treatment against their wishes if they
are psychotic has since been supported by at least 20 studies showing positive
outcomes from enforced treatment [term paper topic?].
________________________________________________________________________
Contemporary
Issues in Mental Health
Service Delivery
A 1990 study done by NAMI of the
quality of state mental health services found Texas ranked 45th with Hawaii in
the 51st spot. If the survey were to be done now Texas would have slipped,
although so would many other states.Hawaii has improved. In per capita spending
on mental health Texas ranked 49th and has not improved even during the booming
1990s. Texas has not closed any state hospitals (5) and has added 500
psychiatric beds in the prison system. The state hospital system cares for many
of the most disabled patients,but has not implemented Gordon Paul's Social
Learning Program despite two excellent opportunities. The first would have cost
the state nothing, but the commissioner of mental health did not believe that
such a hospital program should be run by a psychologist. Not that that would
have been anything new. I was the director of a research-treatment unity at the
VA Hospital in Houston in the 1960s and had a psychiatrist working for me. The Harris County jail has 300 psychiatric
patient-prisoners compared with the Harris County Psychiatric Center with about
200 patients.
New Hampshire received the highest
state rating, but even it had manydeficiencies. One of the authors of the
survey, Fuller Torrey, M.D., went on to do a survey of Canadian provinces. He
concluded that the best state in the USA had poorer services than any province
in Canada. It is also generally recognized that Canada trails Sweden, Holland,
Denmark and France in quality of mental health services.
The Harris County Mental Health
Mental Retardation Authority (MHMRA) serves more people than any other single mental
health authority in the world. When deinstitutionalization was implemented in
the 1960s the expectation was that there would, nationwide, be a community
mental health center for each 60,000 people. In Harris county we have a CMHC
for each 600,000 people and it is no surprise that quality services cannot be
provided for so many people.
In 1990 the MHMRA operated a
psychosocial clubhouse and a bipolar clinic that was staffed by UH clinical
psyhology graduates who provided CBT along with the standard lithium. Both were
highly regarded by clients, but now both are closed and have been converted to
medication clinics. There were three Fairweather Lodges, programs where
ex-patients worked together and lived together in fairly self-sustaining
groups. They cost the state or county nothing except some support staff. They
are gone. There is housing for people
with serious mental illness, but it is indescribably bad. The state does not
supplement Social Security Income (SSI) as many states do and so disabled
people must live on about $540 per month. One cannot provide good room and
board for that.
Do I have nothing good to say about
MHMRA? The staff are hard-working and able. Howver, they are over-worked and
underpaid. They simply cannot perform miracles. The county commissioners and
the state officials need to give them the support they must have to function
well.
There is one good program in
Houston: it is called Magnificat, and it is not connected to MHMRA. This
non-profit program provides housing for 150 people in about 13 houses near the
main campus of the Houston Community College. They operate a psychosocial
clubhouse, have an attractive park and the residents do all of the work except
for what is provided by two women who have been with the program since the
beginning. The program operates a soup kitchen, a thrift shop and emergeny
housing for people who are unexpectedly homeless. It is a remarkable place and,
in my view, the most impressive psychiatric facility in Texas. It manages with
residents' SSi, food stamps, Department of Agriculture surplus food and
whatever.Volunteer workers are welcome.
Clinical Efficacy/Effectiveness
The hottest thing going for clinical
psychology today is the push to follow medicine in providing evidence-based
treatment (EBT). If you develop a migraine headache or skin cancer your doctor
will almost certainly follow the latest recommendations of the research
community in proving your treatment. If you seek help for depression you cannot
be sure what you will get. If you are treated by a UH Clinical Psychology
Program graduate you likely will get EBT, which in this case would be CBT or
Interpersonal Therapy. Both have been well-tested and proven effective.
Efficacy refers to the worth of a
treatment method as evaluated by a carefully designed and operated randomized
control trial. Effectiveness refers to treatment value in standard treatment
settings. Both are important, but they cannot be compared directly.
Effectiveness is more a matter of opinion than of scientific research outcome.
Newer psychologists seem to adopt EBT more readily than older
psychologists who are sometimes reluctant to change their time-honored
practices. The practicing psychologist
has a hard time knowing if her or his treatment is doing any good. Patients who
are helped say nothing, nor do patients who are not helped. As the
psychologists are not in a position to do systematic research they must rely on
the research of others and go to thelibrary or the internet for recent developments.
Professional
Issues
Practicing psychologists must by law
be licensed. Every state has somewhat different laws, but all require
licensure. Ph.D. or Psy.D. psychologists have one form of license and those
with a MA have another. Most MA psychologists are licensed as Licensed
Professional Counselors. Doctoral level
licensure requires graduations from an accredited school, supervised training,
and passing two examinations--one on legal issues and the other on psychology.
A study of how students did not the general examination which is given
nationally found Oregon graduates had highest scores, but UH students were in
the top 10% of about 200 clinical programs.
Graduate Progams in clinical
psychology are highly competitive. UH is typical. The clinical program accepts
8-10 students each year out of about 200 applicants. Accepted students have
solid grade point averages, GREs for verbal, quantitative and Analytical of
about 2000-2100, and letters from undergraduate faculty attesting to their
research abilities. UH also has a doctoral program in Counseling Psychology in
the College of Education and a masters in social work at the School of Social
Work, but I have no information about admission practices. I have been
impressed with their students when they have taken my graduate courses.
Websites
Programs for Jail Diversion
www.psycport.com/2000/11/23E/1933829-0225-Home.html
Confidentiality
www.athealth.com/apps/redirect.cfm?linkid=5
Forensic Psychiatry
www.cc.emory.edu/aap/ethics.htm
*Treatment Advocacy Center www.psychlaws.org
*NAMI www.nami.org
Texas NAMI texas-nami.org
* Especially
good.