16.4 Legal Issues Related to Treatment

In the 1960s and 1970s, the courts decided several landmark cases regarding the rights of the mentally ill. These cases addressed the right to treatment and the right to refuse treatment.

Right to Treatment

In 1966, the Supreme Court ruled that people who are forced to receive treatment through civil commitment should be given the least restrictive alternative treatment available (Lake v. Cameron). That is, they should have the type of treatment that infringes the least on their individual liberties. If a person doesn’t need the 24-hour monitoring and care of an inpatient unit, that person should be treated in a less restrictive environment (such as in a residential setting and with outpatient treatment).

One year after this ruling, the Supreme Court ruled that civil commitment must entail more than warehousing or confining people; the Court ruled that appropriate treatment must also be provided, while recognizing that treatment might not necessarily be successful (Rouse v. Cameron, 1967). In subsequent cases during the 1970s, courts in various jurisdictions outlined specific minimal criteria for such treatment—including the minimum staffing ratio (number of patients per care provider) and number of hours per week of treatment, as well as the need for each patient to have an individualized treatment plan (Wyatt v. Stickney, 1971). The specifics of these requirements differ from jurisdiction to jurisdiction.

The Supreme Court also ruled that civil commitment may not be used simply to confine people against their will indefinitely (except as previously noted with some sexual predators). When patients no longer meet the criteria for commitment (that is, they are no longer dangerous) and can survive independently or with help from willing family members, then they must be discharged (O’Connor v. Donaldson, 1975). The reasoning behind this ruling is that the purpose of the confinement is treatment, and so when inpatient treatment is no longer required, the person should be released.

Right to Refuse Treatment

A federal district court in New Jersey set another standard when it ruled that a civilly committed patient has the right to refuse treatment (Rennie v. Klein, 1978). Generally, this ruling has been applied to a patient’s right to refuse to take medications, most frequently traditional antipsychotics that carry the risk of a serious side effect called tardive dyskinesia (see Chapter 12) (Perlin, 2000b). However, the court did not establish the right to refuse treatment in all situations. As long as there has been a fair and adequate hearing of the issues involved for a given patient, his or her refusal can be overridden after weighing certain factors (Meyer & Weaver, 2006):

• the patient is physically threatening to others (which may include patients and staff members),
• the proposed treatment carries only a small risk of irreversible side effects,
• there are no less restrictive treatment alternatives available, and
• the patient has significantly diminished capacity to decide rationally about particular treatments

Competence to Refuse Treatment

One of the acceptable circumstances for overriding a committed patient’s refusal of a treatment is that he or she does not have the capacity to decide rationally about treatment. Being competent to refuse treatment is different from being competent to stand trial, although both competencies involve some of the same mental processes and abilities. Does being mentally ill imply that a person cannot make rational decisions? One study that investigated the general question of competence to refuse treatment (Appelbaum & Grisso, 1995; Grisso & Appelbaum, 1995) found that about half of patients with schizophrenia performed reasonably well on several tasks assessing their ability to make decisions. Not surprisingly, the more severe the symptoms the less well they performed on the tasks. An even greater proportion of patients hospitalized for depression—about 75%—performed adequately on the tasks that assess decision making. Unlike the patients with more severe symptoms of schizophrenia, patients with more severe depression were generally competent to make decisions. Thus, having a severe mental illness did not routinely make these patients “not competent to refuse treatment.” (Note though that while some individuals who receive outpatient commitment may be competent to refuse treatment, the law may not allow them to refuse.)

Mental Health and Drug Courts

Federal, state, and local court dockets are filled with cases awaiting a hearing or trial. In order to hasten the speed with which cases are resolved, municipalities have instituted specialized courts, such as divorce courts, to address particular types of problems. Two such special courts are particularly relevant to the mentally ill: drug courts and mental health courts.

Drug courts were developed in Miami in 1989 for first-time drug abusers—those whose substance abuse was viewed as the underlying motivation for their crime (Miethe et al., 2000). Soon after arrest, these people were offered an alternative to jail: They could attend a drug treatment program, submit to random and frequent drug testing by urinalysis, and meet with the drug court judge regularly. If they did not show up for a court hearing, a bench warrant would be issued within hours and they could be sent to jail.

The overall goal of drug courts is to help defendants reintegrate into society. Thus, drug courts not only promote intensive treatment for drug abuse and relapse prevention—they also encourage education and employment. Drug court programs do not simply aim to decrease substance abuse; they recognize the complex nature of the factors that contribute to such abuse.

Drug courts recognize that maintaining abstinence can depend on a complex interplay of factors, such as educational opportunities and employment.

John Sundlof/Alamy

Relapse rates are between 4% and 20% for those entering a program and even lower (less than 4%) for those who complete one. Many communities have extended drug court programs to include people who were previously jailed for substance abuse–related crimes, with equivalent success (Drug Court Clearinghouse and Technical Assistance Project, 1998).

The success of drug courts led to the development of mental health courts, which began in Florida and now exist in most states, but not necessarily in most districts (Council of State Governments, 2005). Mental health courts seek to treat, rather than incarcerate, mentally ill people who are charged with a misdemeanor. When mentally ill people receive treatment, they are subsequently less likely to become violent or to reoffend (Dirks-Lindhorst & Linhorst, 2012; Hiday & Ray, 2010).