PSYS 318 FINAL EXAM pt 3

What are the features of effective community care: supervised residences
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What are the features of effective community care: supervised residences
-unable to live on their own/ w their fams
-halfway houses (crisis house/group homes)
-live in staff are usually parapros
-run w a milieu therapy philosophy that emphasizes mutual support, residential responsibility, and self-governing
occupation training and support
-employment provides income, independence, self-respect, and stimulation of working with others brings companionship and order to one's stabile life -> important for schizo
-sheltered workshop: supervised workplace for ppl who are not yet ready for competitive jobs
-replicated a typical work envir
-not consistently available in the US
-alternative work opportunity for ppl w severe psych dis is supported employment
-vocational agencies & counselors help clients find competitive jobs in the community and provide psych support while clients are employed
how has community tx failed?
fewer than 1/2 the ppl that need them receive appropriate community MH services
-b/t 40-60% of all ppl w schizo receive no tx at all
-prim factors responsible: poor coordination of services and a shortage of services
how has community tx failed?: poor coordination of services
-various MH agencies in a com. fail to communicate w one another
-patient may not have continued contacts w the same staff & fail to receive consistent services
-poor communication b/t state hosp. and com. MH centers, particularly at times of discharge
-case managers: a com. ther. who offers a full range of services for ppl w schizo/other service dis., including therapy, advice, meds, guidance, & protection of patients rights; key to success for a comm. prog
how has community tx failed?: shortage of services
-small # available
-com MH centers generally fail to provide adequate services for ppl w severe dis -> spend more time on ppl w less debilitating probs
-reasons for shortage: 1. econ: today more funds are available on one hand; 1963- $1 B, tofay $171 B; on the other hand, little is going toward com tx programs 2. most is going to prescription drugs, monthly income payments (soc. security disability income), services for ppl w mental dis in nursing homes & general hosp. & com. services for ppl who are less disturbed
-financial burden often falls on local gov & nonprofit orgs
what are the consequences of inadequate com. tx?
- L #s receive no tx at all; others spend a short time in a state hosp/semihosp and are then discharged prematurely, often w/o adequate follow up tx
-many survive on gov disability payments, & a # spend their days wandering through neighborhood sts.
-homeless; b/t 400,000 & 800,000 homeless in the US and ~ 1/3 have a sever MH dis, commonly schizo
-others end up in prisons bc their dis have led them to break the law
promise of com. tx
- # of national interest groups have formed in countries around the world that push for better com. tx
-National Alliance on MH: source for info, support, & guidance for members; also a lobbying force in state & national legislatures & it has pressured com. MH centers to tx more ppl w schizo & other severe dis
-today com. care is a major feature of tx for ppl recovering from severe mental dis in countries around the world
law & MH
-2 social institutions have a strong impact on the MH profession: the legislative & judicial systems; protect the public good & the rights of the ind
-psych in law: clinical practitioners & researchers operate w/in the legal system
-law in psych: legislative & judicial systems act upon the clinical field, regulating certain aspects of MH care
-forensic psych: branch of psych concerned w interactions b/t psych practice & research & the judicial system
-may testify in trials, research the reliability of eyewitness testimony, / help police profile the P of a serial killer on the loose
Psych in law: how do clinicians influence the criminal judicial system
-to arrive at justice & appropriate punishments, the courts need to know whether defendants are responsible for the crimes they commit & capable of defending themselves in court
-in some instances ppl who suffer from severe mental instability may not be responsible for their actions/ may not be able to defend themselves in court -> should not be punished in the usual way
-guided by opinions of MH professionals
-criminal commitment: legal process by which ppl accused of crime are instead judged mentally unstable and sent to a tx facility; several forms
1.ppl are judged mentally unstable @ the time of their crimes -> innocent of wrongdoing
-may plead not guilty by reason of insanity
-committed for tx until they improve enough to be released
2. ppl are judged mentally unstable @ the time of their trial; considered unable to understand the trial procedures & defend themselves in court
-committed for tx until they are competent to stand trial
criminal commitment & insanity during commission of crime
-prosecution provoking the defendant to be sane beyond reasonable doubt
-few years later, congress passes making it the defenses burden in federal cases that defendants are sane
-"insanity" is a legal term written by legislators, not clinicians
-M'Naghten test. M'Naghten rules: legal test for insanity that holds ppl to be insane at the time they committed a crime if, bc of a mental dis, they did not know the nature of the act/did not know right from wrong
-irresistible impulse test: legal test for insanity that holds ppl to be insane at the time they committed a crime if they were driven to do so by an uncontrollable "fit of passion"
-Durham test: legal test for insanity that holds ppl to be insane @ the time they committed a crime if their act was the result of mental dis/defect
-too flexible; insanity defenses could point to alc/other forms of SA, headaches, / ulcers
-1955, American Law institute formulated a test that combines aspects of the M'Naghten, irresistible impulse, and Durham tests
-American Law institutional test: legal test for insanity that holds ppl to be insane @ the time they committed a crime if, bc of a mental dis, they did not know right from wrong/could not resist an uncontrollable impulse to act
-After Hinckley verdict, there was a public uproar over the "liberal" ALI guidelines, & ppl called for tougher standards
-in 1983, the American psychiatric association recommended that ppl should be found not guilty by reason of insanity only if they did not know right from wrong @ the time of the crime; an inability to control themselves & to follow the law should no longer be a sufficient grounds for judgements of insanity -> return to the "M'Naghten test"
-2/3 of defendants who are acquitted of a crime by reason of insanity qualify for a diag of schizo
-1/2 are white & 86% are M (M= 32 yrs old)
what concerns are raised by the insanity defense?-fundamental differ between the law & science of human b: law- ind have free will and are responsible for their actions; human b- assume that physical/psychological forces act to determine the ind's b -uncertainty of scientific knowledge about abnormal b: testimony of defense clinicians conflict w that of clinicians hired by prosecution, so the jury must weigh the claims of "experts" who disagree in their assessments; even w the helpful scales, it is hard to evaluate a defendant's state of mind during an event that took place weeks, months, / years earlier; due to mental states being able to change over time & situations, clinicians can never be entirely certain that their assessment of mental instability @ time of crime is accurate -allows dangerous criminals to escape punishment; in reality, only 1%; 26% of those who plead insanity are actually found not guilty -during most of US history, a successful insanity plea= a LT prison sentence; sometimes spent even more time in tx -1992- case of Foucha vs. Louisiana, the US supreme court clarified that the only acceptable basis for determining the release of hospitalized offenders is whether/not they are still "insane," they cannot be kept indefinitely in mental hosp bc they are dangerous; may insist on com. tx, monitor patients closely, and rehosp if necessarywhat other verdicts are available?-guilty but mentally ill: defendants are guilty of committing a crime but are also suffering from a mental illness that should be tx during imprisonment -found unsatisfactory; has not lowered the # of guilty by reason of insanity verdicts & often confuses jurors; also, appropriate health care is supposed to be available to all prisoners anyway -guilty w diminished capacity: a defendants mental dys is viewed as an extenuating circumstance that the court should take into consideration in det the precise crime in which they are guilty; can be found guilty of a lessor crime; not usedwhat are sex-offender statutes-mentally disordered sex offenders: repeatedly found guilty of sex crimes -> mental dis -sent to a MH facility instead of prison; helps protect them from physical abuse in prison -many states abolished this; law is diff to apply; some of the laws require the offender to be found "sexually dangerous beyond a reasonable doubt" -in order to be classified as a mentally disturbed sex offender, the person must be a good candidate for tc -racial bias; whites are 2X as likely to be allowed to do tx instead of prison -prim reason: state legislation & courts are now less concerned than they used to be about the rights & needs of sex offenders, given the growing # of sex crimes taking place across the country, particularly ones in which children are victims -21 states & the federal gov have instead passed sexually violent predator laws: call for certain sex offenders who have been convicted of sex crimes & have served their sentence in prison to be removed from prison b4 their release & be committed involuntarily to a mental hosp for tx if a court judges them likely to engage in further "predatory acts of violence" as a result of "mental abnormality/ p dis" -jurors attach more weight to the severity of the sexual acts man to the statistical probability that the person will again commit such actscriminal commitment & incompetence to stand trial-mental incompetence: state of mental instability that leaves defendants unable to understand the legal charges and proceeding they are facing & are unable to prep an adequate defense w their attorney -issue of competence is most often raised by the defendant's attorney -on the side of caution bc some convictions have been reversed on appeal when a defendant's competency was not established at the beginning -incompetence -> judge orders a psych eval -if incomp -> defendant is typically assigned to a MH facility until comp to stand trial; can last a long time -after a reasonable amount of time, they should either be found comp & tried, set free, / transferred to a MH facility under civil commitment proceeding -until the 1970s, most states required that mentally incomp be committed to max security institutes for the "criminally insane" -now, more flexible -jail diversion: person is "diverted" from jail to the com. for MH carelaw in psych, how do the legislative & judicial systems influence MH careq-legal system has a major impact on clinical practice -courts & legislation have dev the process of civil commitment which allows certain ppl to be forced in MH tx -the legal system, on behalf of the state, has taken on the responsibility of protecting patients' rights during tx; protection for vol/involcivil commitment-committed to mental institution/outpatient civil commitment laws allow patients to be forced into com. tx programs -in some ways, thee law provides more protection for ppl suspected of being criminals that for ppl suspected for being psychoticwhy com. mh?-when they are considered to be in need of tx & dangerous to themselves or others -suicidal/reckless -seek to harm others/unintentionally place others @ risk -protect interest of the ind and of society:the principles parens patrial and police power -parens patrial ("parent of the country": the state can act on to protect patients from self-harm, including invol. hospitalizing them -police power: allows state to take steps to protect society from a person who is dangerouswhat are the processes for civil commitment-vary from state to state -some are basic & common to most of laws -often fam members begin commitment proceedings -if a minor, the supreme court has ruled that a hearing is not necessary, as long as a qualified MH professional considers commitment necessary -if an adult, the court will order a mental exam & allow the person to contest the commitment in court, often represented by a lawyer -Addington vs Texas (1979) outlined the minimum standard of proof needed for commitment -b4 commitment, there must be "clear and convincing" prood that they are mentally ill & has met the states requirement for invol. commitment -must provide 75% certainty that the criteria of commitment has been met -far less than the near-total certainty requirement to convict ppl of committing a crimewho is dangerous?-in the past, ppl w mental dis were less likely than others to commit violent/dangerous acts -related to the fact that many lived in institutions -dis w the strongest relationship to violence are sever SUD, impulse ctrl dis, & antisocial p dis., & psychotic dis -research suggest that psychiatrists and psychologists are wrong more than right when they make LT predictions of violence -they overestimate the likelihood that a patient will eventually be violent -ST predictions-prediction of imminent violence- find to be more accurateWhat are the probs w civil commitment?-difficultly of assessing a persons' dangerousness -legal definitions of "mental illness" & "dangerousness" are vague -sometimes questionable therapeutic values of civil commitment -many ppl commit invol. do not respond well to therapy -suggest abolishing invol. commitment & suggest instituting a process of risk assessment that would arrive at statements "the patient is believed to have ___ likelihood of being violent to the following ppl/under the following condition over ____ period of time"trends in civil commitment-1962: Robinson vs California, supreme court ruled that imprisoning ppl who suffer from drug addiction might violate the constitution's ban on cruel & unusual punishments & it recommended invol. civil commitment to a mental hosp as a more reasonable action -this encourages the civil commitment of many kinds of "social deviants" -invol. committed patients found it particularly difficult to obtain release -as the public became more aware of these issues, state legislation started to pass stricter standards about invol. commitment -some states spelled out specific types of b that a person had to show before they could be determined dangerous -rates on invol. commitment decreases and release rates increaseProtecting patients rights: how is the right to tx protected?-right to tx: the legal right of patients, particularly those who are invol. comm. to receive adequate tx -bc conditions in state hosp were so terrible, the judge lead out goals that state officials had to meet, including more therapists, better living cond., more privacy, more social interactions & physical exercise, & a more proper use of physical restraints and meds -must review patients cases periodically -state cannot continue to institutionalize ppl against their will if they aren't dangerous & are capable of surviving on their own/ w help of responsible fam members/ friends -ppl committed involuntarily have a right to "reasonably nonrestrictive confinement conditions" as well as "real care &. safety" -congress passed the protection & advocacy for mentally ill ind. act in 1986 -gave patients the power to investigate possible abuse & neglect & to correct these probs legally -public advocates have argued that the right to tx should be extended to the tens of thousands of ppl w severe mental dis who are repeatedly released from hosp. into ill equipped communitiesProtecting patients rights: how is the right to refuse tx protected?-right to refuse tx: the legal right of patients to refuse certain forms of tx -rulings usually target one specific tx at a time -most center on bio tx; right to refuse psychosurgery; right to refuse ECT; # of state's continue to permit ECT to be forced on committed patients, whereas others require consent of a close relative/other 3rd party -in the past, patients didn't have the right to refuse psychtropic med -due to the powerful & danger of these meds, some states have granted patients the rights to refuse meds -if patients refusal is considered incompetent, dangerous, / irrational, the state may allow it to be overturnedwhat other rights do patients have?-patients who perform work in mental institutions are guaranteed at least a minimum wage -1974: patients released from state mental hosp. have a right to aftercare & to an appropriate community residence, such as a group home -ppl w psych dis should receive tx in the least restrictive facility availablethe rights debate-many clinicians express concerns that the patients rights rulings & laws may unintentionally deprive them of opportunity for recoveryin what other ways do the clinicians legal fields interact?: Law in psychology: malpractice suits-the # of malpractice suits (lawsuit charging a therapist w improper conduct in the course of tx) has risen so sharply in recent years that clinicians have coined terms for being sued- litigaphopia & litigastress -claims have been made against clinicians in response to a patients attempted suicide, sexual activity with a patient, failure to obtain informed consent for a tx, neglected drug therapy, omission of drug therapy that would speed improvement, improper termination of tx, & wrongful commitmentin what other ways do the clinicians legal fields interact?: Law in psychology: law in psych: professional boundaries-given more authority to psychologists & blurred the lines that once separated psychiatry from psychology -a growing # of states are ruling that psychologists can admit patients to the state's hosp., a power previously held only by psychiatrists -in 1991, the department of defense started to reconsider the biggest difference of all between the practices of psychiatry and psychology- the authority to prescribe drugs -APA recommended that all psychologists be allowed to attend a special educational program in prescription services & receive certification to prescribe meds if they pass -professional association of psychology, psychiatry, & social work lobby in state legislation across the country for laws & decisions that may increase the authority of their members, a further demonstration of the way the MH system interacts w other sectors of our societyin what other ways do the clinicians legal fields interact?: Law in psychology: psych in law: jury selection-"jury specialists"- advise lawyers about which potential jurors are likely to favor their side & which strategies are likely to win jurors' support during trials -make suggestions based on surveys, interviews, analyses of jurors backgrounds & attitudes, & lab simulations of upcoming trials -validity?in what other ways do the clinicians legal fields interact?: Law in psychology: Psych in law: psych research of legal topics-sometimes conducted studies & dev expertise on topics of great importance to the CJ system -> influence the system -eyewitness testimony -75% of wrongful convictions were based on mistaken eye witness testimony -highly unreliable -most crimes are unexpected & fleeting -> not the sort of events that are remembered well -distractions may be present -may have other things on their minds- concern for their own safety/ that of bystandars; greatly impairs later mems -in lab studies, researchers found it easy to fool research participants who are trying to recall the details of an observed event simply by introducing misinfo -ppl who are highly suggestible have the poorest recall of observed events -for ID actual perpetrators, the accuracy is heavily influenced by the methods used in ID -police lineup -> not always reliable -confidence does not = accuracy; yet the degree in confidence influences the jurors -hypnosis is prohibited due to the ability of producing false mems -patterns of criminality -psych profiles of perps -high, but not as influential as what TV portrays -shared # of traits & backgrounds of certain criminals; not always present though -helpful as long as the limitations of profiling are recognizedwhat ethical principles guide MH professionals?-clinicians don't rely exclusively on the legislative & court systems to ensure proper & effective clinical practice -regulate themselves by continuing dev & revising ethical guidelines for their work & b -each profession w/in MH field has its own code of ethics: a body of principles & rules for ethical b, designed to guide decisions & actions by members of a profession -APA: 1. psychologists are permitted to offer advice, provided they do so on appropriate psych lit & practices 2. Psychologists may not conduct fraudulent research, plagiarize the work of others, / publicly falsify data 3. Psychologists must acknowledge their limitations w regard to patients who are disabled/ whose gender, ethnicity, language, SES, / sexual orientation differs from that of the therapist -often requires therapists to obtain additional training/supervision, consult w more knowledgable colleague, / refer to more appropriate professionals 4. Psychologists who make evaluations & testify in legal cases must base their assessments on sufficient info & substantiate their findings appropriately 5. Psychologists may not take advantage of clients & students, sexually/ otherwise -forbids a sexual relationship w a present/former client for at least 2 years after the end of tx -4-5% engage in some form of sexual misconduct -80% of therapists reported having been sexually attracted to a client but few acted on these feelings 6. psychologists must adhere to the principle of confidentiality -confidentiality: principle that certain professionals will not divulge the info they obtain from a client with the exception of a therapist in training to a supervisor, or if they are a danger to themselves/others -duty to protect: therapists must break confidentiality in order to protect a person who may be the intended victim of a client