Contemporary andLegal Issues inAbnormal Psychology

PERSPECTIVk:S ON PREVENTIONUniversal InterventionsSelective InterventionsIndicated InterventionsThe Mental Hospital as a Therapeutic CommunityDeinsti tu tionaliza tion

CONTROVERSIAL LEGAL ISSUES AND THEMENTALLY DISORDEREDThe Commitment ProcessAssessment of "Dangerousness"The Insanity Defense

ORGANIZED EFFORTS FOR MENTAL HEALTHU.S. Efforts for Mental HealthInternational Efforts for Mental Health

CHALLENGES FOR THE FUTUREThe Need for PlanningThe Individual's Contribution

UNRESOLVED ISSUES:The HMOs and Mental Health Care

e have covered a great many topics and issues pertinent to a modern under-standing of abnormal behavior on these pages. The final chapter of this bookhas traditionally been somewhat of a forum for several important topics inabnormal psychology that have been noted only briefly in earlier chapters.These issues are very important to understanding the field of abnormal psy-chology and will give the reader a broader perspective on ways our societydeals with, or in some cases fails to deal with, abnormal behavior. We beginwith the topic of prevention of mental disorders. Over the years, most mentalhealth efforts have been largely restorative, geared toward helping people afterthey have already developed serious problems. Albee (1999) cogently makesthe case that if the goal is the reduction or elimination of emotional problemsin our country or the world, then a major revolution in thinking is required-theexpansion of efforts at prevention.

Next, we will describe inpatient mental health treatment and the state ofmental hospitals in contemporary society. We will discuss changes that havetaken place and some of the forces that have affected inpatient psychiatric caretoday. Following this, several legal issues pertinent to psychiatric care and thehospitalization of people with severe psychological problems will be addressed.We will then briefly survey the scope of organized efforts for mental health bothin the United States and throughout the world. Finally, we will consider whateach of us can do to foster mental health.

PERSPECTIVES ONPREVENTIONIn the past the concepts of primary, secondary, and tertiaryprevention were widely used in public health efforts todescribe general strategies of disease prevention. The ter-minology was derived from public health strategiesemployed for understanding and controlling infectiousphysical diseases, and was thought to provide a useful per-spective in the mental health field as well. However, foryears there was relatively little progress in prevention.Heller (1996), for example, noted that "Until the lastdecade anything approaching a true prevention science didnot exist" (p. 1124). In the early 1990s, the U.S. Congressdirected the National Institute of Mental Health (NIMH)to work with the Institute of Medicine (lOM) to develop areport detailing a long-term prevention research program.Among other things, the 10M report focused attention onthe distinction between prevention and treatment efforts(Dowis, 2004; Dowis & Dobson, 2004; Munoz, 2001;Munoz, Mrazek, & Haggerty, 1996). Prevention efforts arenow classified into three subcategories:

1. Universal interventions: Efforts that are aimed atinfluencing the general population.

2. Selective interventions: Efforts that are aimed at aspecific subgroup of the population considered atrisk for developing mental health problems-for

example, adolescents or ethnic minorities (Coie,Miller-Johnson, & Bagwell, 2000).

3. Indicated interventions: Efforts that are directed tohigh-risk individuals who are identified as havingminimal but detectable symptoms of mental disorderbut who do not meet criteria for clinical diagnosis-for example, individuals forced from their homes bya flood or some other disaster.

As shown in Figure 18.1, preventive efforts areclearly differentiated from treatment and maintenanceinterventions.

Universal interventions perform two key tasks: (1) alteringconditions that can cause or contribute to mental disor-ders (risk factors) and (2) establishing conditions thatfoster positive mental health (protective factors). Epidemi-ological studies (see Chapter 1) help investigators obtaininformation about the incidence and distribution of vari-ous maladaptive behaviors (Dowis & Dobson, 2004) suchas anxiety-based disorders (Feldner, Zvolensky, & Schmidt,2004). These findings can then be used to suggest whatpreventive efforts might be most appropriate. For example,various epidemiological studies and reviews have shownthat certain groups are at high risk for mental disorders:recently divorced people (Theun, 2000), the physically dis-abled (Mitchell & House, 2000), elderly people (King &

Markus, 2000), physically abused children (Hamerman &

Classification of Prevention Strategies, Treatment. and MaintenanceThe traditional terminology for describing general strategies of disease prevention in the field of public health has been revised toprovide a more useful perspective on prevention efforts. The new classification system for prevention (universal, selective, and indicatedstrategies) is shown in this context as distinct from treatment interventions and maintenance approaches to mental health problems.Source: From Reducing Risks for Mental Disorders: Frontiers for Preventive Research, edited by P.j. Mrazek and R.]. Haggerty. Copyright © 1994 by theNotional Academy of Sciences. Courtesy of the National Academy Press, Washington, DC.

Ludwig, 2000), people who have been uprooted from theirhomes (Caracci & Mezzich, 2001), and victims of severetrauma (Jaranson, Butcher, et al., 2004). Although find-ings such as these may be the basis for immediate selectiveor indicated prevention, they may also aid in universalprevention by telling us what to look for and where tolook-in essence, by focusing our efforts in the rightdirection. Universal prevention is very broad and includesbiological, psychosocial, and sociocultural efforts. Virtu-ally any effort that is aimed at improving the human con-dition would be considered a part of universal preventionof mental disorder.

BIOLOGICAL STRATEGIES Biologically based universalstrategies for prevention begin with promoting adaptivelifestyles. Many of the goals of health psychology (seeChapter 10) can be viewed as universal prevention strate-gies. Efforts geared toward improving diet, establishing aroutine of physical exercise, and developing overall goodhealth habits can do much to improve physical well-being.Physical illness always produces some sort of psychologicalstress that can result in such problems as depression, sowith respect to good mental health, maintaining goodphysical health is prevention.

Preventing mental disorders and maintaining psychosocial healthrequire that a person be prepared for the types of problems likelyto be encountered during given life stages. For example, youngpeople who want to marry and have children must be prepared forthe tasks of building a mutually satisfying relationship andhelping children develop their abilities.

PSYCHOSOCIAL STRATEGIES In viewing normality asoptimal development and viewing high functioning(rather than the mere absence of pathology) as the goal, we

imply that people need opportunities to learn physical,intellectual, emotional, and social competencies.

1. The first requirement for psychosocial "health" isthat a person develop the skills needed for effectiveproblem solving, for expressing emotionsconstructively, and for engaging in satisfyingrelationships with others. Failure to develop these"protective" skills places the individual at a seriousdisadvantage in coping with stresses and theunavoidable risk factors for mental disorder.

2. The second requirement for psychosocial health isthat a person acquire an accurate frame of referenceon which to build his or her identity. We have seenrepeatedly that when people's assumptions aboutthemselves or their world are inaccurate, theirbehavior is likely to be maladaptive. Consider, forexample, the young woman who believes that beingthin can bring happiness and so becomes anorexic.

3. The third requirement for psychosocial health is thata person be prepared for the types of problems likelyto be encountered during given life stages. Forexample, young people who want to marry and havechildren must be prepared for the tasks of building amutually satisfying relationship and helping childrendevelop their abilities. Similarly, a middle-aged adultneeds to be prepared for problems that are likely toarise during retirement and old age.

In recent years, psychosocial measures aimed at pre-vention have received a great deal of attention. The field ofbehavioral medicine has had substantial influence here. Aswe saw in Chapter 10, efforts are being made to change thepsychological factors underlying unhealthful habits suchas smoking, excessive drinking, and poor eating habits.

SOCIOCULTURAL STRATEGIES As has been demon-strated many times throughout this book, without a sup-portive community, individual development is stifled. Atthe same time, without responsible, psychologicallyhealthy individuals, the community will not thrive and, inturn, cannot be supportive. The psychosocially impairedvictims of disorganized communities lack the wherewithalto create better communities to protect and sustain thepsychological health of those who come after them, and apersistently unprotective environment results. Socio-cultural efforts toward universal prevention are focused onmaking the community as safe and attractive as possiblefor the individuals within it.

With our growing recognition of the role that patho-logical social conditions play in producing maladaptivebehavior (in socially impoverished communities), increasedattention must be devoted to creating social conditionsthat will foster healthy development and functionin6 inindividuals. Efforts to create these conditions include abroad spectrum of measures-ranging from public educa-

tion and Social Security to economic planning and sociallegislation directed at ensuring adequate health care for all.

Preventing mental health problems through social changein the community is difficult. Although the whole psycho-logical climate can ultimately be changed by a social move-ment such as the civil rights movement of the 1960s, thepayoff of such efforts is generally far in the future and maybe difficult or impossible to predict or measure. Attemptsto effect psychologically desirable social change are alsolikely to involve ideological and political issues that mayinspire powerful opposition, including opposition fromgovernment itself. According to an analysis by Humphreysand Rappaport (1993), for example, the Reagan and Bushadministrations during the 1980s severely undercut Com-munity Mental Health Center social programs in favor ofagencies involved in the "war on drugs." This effort, in redi-recting attention and funds to purported defects of indi-vidual character, was said to be more in keeping with aconservative political philosophy that viewed the basicproblem as one of personal moral weakness, not social dis-organization. ("How should kids deal with a drug-satu-rated environment? Just say no.") Although drug abuse is amatter of individual behavior, it does not follow that allcountermeasures must or should be directed at the indi-vidual. Some examples of more selective and effective pro-grams will be discussed in what follows.

AN ILLUSTRATION OF SELECTIVE PREVENTIONSTRATEGIES Though difficult to formulate and evenmore difficult to mobilize and carry out, selective interven-tion can bring about major improvements. In this section,we will look at the mobilization of prevention resourcesaimed at curtailing or reducing the problem of teenagealcohol and drug abuse. Prominent social forces such asattractive television advertising, the influence of peergroups, negative parental role models, and the ready avail-ability of many drugs are instrumental in promoting theearly use of alcohol in young people. In some CentralAmerican countries, increasingly greater numbers of ado-lescents are succumbing to drug habits as a result of drugtraffickers using youth, whom they consider forms ofcheap labor, and who can more easily escape prosecution.The extent of drug use among adolescents is increasingsubstantially in Guatemala, EI Salvador, Honduras, andNicaragua (Boddiger, 2004).

Recent years have witnessed a decrease in the rate ofalcohol and marijuana use (National Institute of DrugAbuse, 2004) in the United States. However, teenage alcoholand drug use remains one of the most significant psycho-logical community problems (Ellickson, D'Amico, et al.,2005), and adolescent use of pain killers has increased. Forexample, Vicodin was used by 9.3 percent of twelfthgraders, 6.2 percent of tenth graders, and 2.5 percent of

eighth graders in the past year, and OxyContin was used inthe past year by 5 percent of twelfth graders, 3.5 percent oftenth graders, and 1.7 percent of eighth graders. The prob-lem of teenage drinking, particularly binge drinking, is sig-nificant among adolescents from minority groups such asAmerican Indians, who are at especially high risk for sub-stance-related problems given that their current alcoholuse rate is extremely high. One recent survey of Bureau ofIndian Affairs schools showed that 48.8 percent of thesample currently reported alcohol use, with 80 percent ofthe sample indicating lifetime use; three-quarters of thesample reported a lifetime use of marijuana (Centers forDisease Control, 2003). In another study, Ramirez, Crano,et al. (2004) found that Hispanic Americans showed higherusage of marijuana and inhalants than Anglo-Americans.

Heavy alcohol use among young people can lead totragic consequences such as impaired driving (Lewis,Thombs, & aids, 2005). Because the factors that entice ado-lescents to begin using alcohol and drugs are seeminglyunder social control, it is tempting to think that if theseforces could be counterbalanced with equally powerfulalternative influences, the rate of substance abuse mightradically decline. But this is easier said than done. Our gov-ernment has approached the drug-abuse problem withthree broad strategies, all of which have proved insufficient:

1. Interdicting and reducing the supply of drugsavailable. The reduction of supply by policing ourborders has had little impact on the availability ofdrugs. Drug interdiction programs do little to affectthe supply of the two drugs most abused byadolescents-alcohol and tobacco-which are, ofcourse, available in corner stores and even in theadolescent's home. Reducing the supply of thesedrugs to adolescents seems virtually impossible.

2. Providing treatment services for those who developdrug problems. Although much money is spenteach year on treatment, treating substance abuse isperhaps the least effective way to reduce the problem.Addictive disorders are very difficult to overcome,and treatment failure-relapse is the rule rather thanthe exception. Therapeutic programs for thoseaddicted to drugs or alcohol, though necessary, arenot the answer to eliminating or even significantlyreducing the problems in our society.

3. Encouraging prevention. By far the mostdesirable-and potentially the most effective-means of reducing the drug problem in our countryis through prevention methods aimed at alertingcitizens to the problems that surround drugs andteaching young people ways to avoid using them(Hawkins, Cummins, & Marlatt, 2004; Sussman,Earleywine, et al., 2004). Although past efforts havehad some limited success in discouraging adolescentdrug use, many initially promising prevention effortshave failed to bring about the desired reduction in

Efforts to teach schoolchildren about the dangers of drugs beforethey reach the age of maximum risk are based on the premise thatif children are made aware of the dangers of drugs and alcohol,they will choose not to use them.

substance use. There are a number of reasons for this:The intervention typically has not been conductedfor long enough to show the desired effect; theintervention efforts have not been powerful enoughto make a sufficient impact on the participants; orthe strategy may not have been well implemented.

It is clear that traditional health or psychologicalintervention models aimed at individual remediation onlyafter a youngster has become addicted to narcotics or alco-hol have not significantly reduced the problem of drug andalcohol abuse among teenagers. Moreover, these treatmentapproaches are typically implemented only after the childhas seriously compromised his or her life opportunitiesthrough drug or alcohol use. Recent epidemiologicalresearch has confirmed that early alcohol use is a strongpredictor of lifetime alcohol abuse and dependence (Grant& Dawson, 1997). In recent years, therefore, preventionspecialists have taken a more proactive position. They haveattempted to establish programs that prevent the develop-ment of abuse disorders before young people become soinvolved with drugs or alcohol that future adjustmentbecomes difficult, if not impossible. These recent preven-tion strategies have taken some diverse and promisingdirections. We will examine several such efforts and thendiscuss the limitations of these prevention approaches.

Education Programs Many drug and alcohol educationprograms are school based and are predicated on the ideathat if children are made aware of the dangers of drugs andalcohol, they will choose not to begin using them. Englan-der-Golden and colleagues (1986), for example, provided"Say it straight" training, in which they taught sixththrough eighth graders both the dangers of drug and alco-hol abuse and how to be assertive enough to resist drugsand alcohol in spite of peer pressure. In a follow-up evalu-ation, these investigators reported that youngsters whowere trained in the program had a lower rate of drug- and

alcohol-related suspensions from school than childrenwho received no training. Another school-based preven-tion program developed by the organization MothersAgainst Drunk Driving (MADD) involves the use of asafety curriculum for third, fourth, and fifth graders,taught by high school peer leaders, tomake young children aware of the risksof underage consumption of alcoholicbeverages and vehicle-related risks,especially when they are passengers invehicles in which the driver is notalcohol-free. The curriculum benefitsstudents by influencing their attitudestoward advertisements and increasingtheir intentions not to ride in a carwith a driver who has been drinking(Bohman, Barker, et al., 2004).

Peer Group Influence Programs Peers exert a powerfulinfluence on teenagers in every aspect of their lives includ-ing drug and alcohol abuse. Programs designed to helpyoungsters overcome negative pressures from peers focuson teaching social skills and assertiveness. Of course, peer

pressure can influence a teen not to usedrugs or alcohol (Orman, Veseley, et al.,2004). Peer influence seems much morepowerful than the influence of adults,including teachers and parents, particu-larly when parents and schools fail tosupervise students adequately (Voelki &Frone,2000).

intervention programs forhigh-risk populations

This research strategy involvesidentifying high-risk individualsand providing special approachesto circumvent their problems; forexample, identifying adolescents atrisk for abusing alcohol andimplementing a program toprevent the problem behavior.Intervention Programs for High-Risk

Teens Intervention programs identifyhigh-risk teenagers and take specialmeasures to circumvent their further use of alcohol orpotentially dangerous drugs (Hawkins, Cummins, & Mar-latt, 2004). Programs such as these are often school-basedefforts and are not strictly prevention programs. One suchprogram involved the early identification of young peoplewho were having difficulties in school because of drug andalcohol use. Teachers and administrators were trained toidentify and counter problems with alcohol and drug usethrough a fair and consistently enforced drug and alcoholpolicy in the schools (Newman et al., 1988-89).

Parent Education and Family-Based Intervention Pro-grams Through their own drinking or through positiveverbalizations about alcohol, parents may encourage orsanction alcohol use among teens. Some research hasshown that parental involvement and monitoring reducessubstance use among adolescents (Ramirez, Crano, et al.,2004). Thus, some prevention programs focus upon familyinterventions (Spoth, Redmond, et al., 2004) with goodsuccess. Sieving, Maruyama, et al. (2000) found thatalcohol-related cognitions among teenagers were directlyrelated to parental norms. Moreover, parents typicallyunderestimate their own children's drug and alcohol use(Silverman & Silverman, 1987). Because of these factors,several programs have been aimed at increasing parents'awareness of the extent of the problem and at teachingthem ways to deal with drug and alcohol use in the familycontext (Kumpfer, 2000). One such program worked withparents whose children were about to become teenagers(Grady, Gersick, & Boratynski, 1985). It first assessed par-ents' skills in dealing with drug-related issues and thentrained parents to understand and respond empathicallyto youngsters who might be exposed to drugs during theiradolescent years. Parents were next taught how to respondeffectively to their children's questions and concerns and tohelp them consider alternative, more adaptive behavior.

Programs to Increase Self-EsteemPrograms designed to increase a sense ofself-worth attempt to ensure that youngpeople will be able to fend for them-selves with more confidence and notfall into dependent, negative relation-ships with stronger and more dominant

peers. One such program provided teenagers with social-skills training and the modeling of appropriate behaviorsto reduce drug use and related negative behaviors such astruancy (Pentz, 1983). In another program, Botvin (1983)relied on cognitive-behavioral intervention techniques(for example, self-talk) to enhance teenagers' feelings ofcompetency in basic life skills and to improve theirproblem-solving skills. This approach has been thought tobe effective in reducing the impact of tobacco, alcohol, andmarijuana use (Botvin et al., 1990).

Mass Media and Modeling Programs Recognizing thehuge "market" potential of teenagers, advertisers havebecome adept at exploiting the tremendous value that the

Peer programs, like those offered at the Boys and Girls Clubs,focus on the positive aspects of peer pressure. Peers can exertmuch more influence over teen behavior than can adults in a/laspects of life, including avoiding drug and alcohol abuse.

appearance of sophistication has for this age group. Mostyoungsters are bombarded with drug- or alcohol-relatedstimuli in movies and in TV commercials that are aired atthose times when children are most likely to view them.Some legal prohibitions of such exploitation are now inplace. And several efforts have been aimed at deglamoriz-ing or counteracting these messages by showing commer-cials that graphically depict the negative aspects of alcoholand drug use (Schilling & McAlister, 1990).

Combined Prevention Programs The various preven-tion strategies discussed here are by no means mutuallyexclusive, and some approaches do not rely on a singleintervention strategy but incorporate two or more (Wage-

naar, Murray, et aI., 2000). Project Northland-an exem-plary program of research geared toward the prevention ofalcohol abuse-targets junior high school students innortheastern Minnesota but also involves a much broader,community-wide intervention effort (Komro, Perry, et aI.,2004; Perry, Williams, Komro, & Veblen-Mortenson,2000). This program is discussed in Developments in Prac-tice 18.l.

These projects have clearly shown an effective pathtoward reducing the extent of substance abuse in youngpeople. Armed with appropriate information and havinghad some practice at resisting others around them, ado-lescents can stick to the decision not to use alcohol ordrugs. The visible success of these programs has come to

8.1

Teenage drinking is a major social problem inthe United States. Johnson, O'Malley, andBachman (2000) reported that 80.3 percent oftwelfth graders, 71.4 percent of tenth graders,and 51.7 percent of eighth graders have had

more than "a few sips" of alcohol. Project Northland is aresearch study designed to prevent or reduce alcohol useamong adolescents via a multilevel community-basedapproach (Komro, Perry, et aI., 2004; Perry, Williams,Komro, Veblen-Mortenson, et aI., 2000; Perry & Williams,et aI., 2001). The investigators conducted their program in24 school districts in northern Minnesota, an area thatwas notorious for high rates of substance abuse. Assess-ments were made annually to measure the use of alcoholamong the identified target population and the controlsamples. The program employs a number of forms of inter-vention: a social-behavioral curriculum in the schools tomake students aware of the issues, parent education pro-grams, peer leadership, and community-wide activities toalter the messages that young people typically receiveabout alcohol. In this program, students complete fouractivity booklets as homework assignments with their par-ents over a period of 4 weeks. Each booklet includes activ-ities that contain explicit behavioral objectives (forexample, how to establish family rules about drinking).Elected peer leaders give students activity tasks eachweek, with the assistance of their teachers. These ses-sions are conducted in small groups.

Before the intervention program begins, teachersreceive a 4-hour training session. Elected peer group lead-ers attend a 2-hour training session. During the interven-tion phase of the program, each child is asked to displayscore cards (signed by parents to record participation) on aprominent scoreboard. Students receive prizes (e.g., a pen)for completion of the first two booklets and a T-shirt at the

end of the program. The program ends with an event ateach school that brings fifth graders and their parentstogether for an evening program. During the week beforethe evening event, students work in pairs on posters withalcohol-related messages that are presented to parentsduring the evening event.

Project Northland staff have been able to maintainbroad participation in the program for over 3 years andhave shown that multilevel, targeted prevention programsfor young adolescents are effective in reducing alcohol useamong adolescents. Adolescents in the experimental con-dition show clearly lower levels of alcohol use than adoles-cents in the control schools. Alcohol use, cigarettesmoking, and marijuana use by adolescents was reduced21 percent more in the intervention schools than in thecontrol schools.

Another study of an extensive and comprehensivesubstance-abuse prevention program was completed byBotvin and his colleagues (Botvin et aI., 1995). This pro-gram involved 3,597 adolescents in 56 public schools,who were followed for 5 years beginning in the seventhgrade. The initial intervention consisted of 15 classes, 10booster sessions in the eighth grade, and 5 booster ses-sions in the ninth grade. The adolescents were taught spe-cific drug resistance skills and general life skills in aclassroom-based program. Like the Northland Project, thisstudy found that drug-abuse prevention programs con-ducted during junior high school can produce significantand durable reductions in tobacco, alcohol, and marijuanause if they teach social resistance skills and if booster ses-sions are provided. There were 44 percent fewer drugusers and 66 percent fewer polydrug users (tobacco, mari-juana, and alcohol) in the prevention group than in thecontrol schools.

Recognizing the huge "market" potential of teenagers, advertisers exploit the tremendous value that the appearance of sophistication has forthis age group. Some efforts have been aimed at deglamorizing these messages by showing ads that graphically depict the negative aspectsof a/cahol and drug use, like the antismoking ad on the right.

the attention of educators in other school districts, and anumber of efforts are under way to "export" these labora-tory programs for broader use in America's schools.Recently, the Northland approach has been adapted forprevention projects in Croatia, Russia, and Poland as ameans of fighting alcohol abuse-one of the most serioushealth problems in those countries (Abatemarco, West,et al., 2004; Okulicz-Kozaryn, Bobrowski, et al., 2000;Ostaszewski, Bobrowski, et al., 2000; Williams, Grechanaia,et al., 2001).

The jury is still out on the relative success of the vari-0us substance-abuse prevention programs at reducingalcohol and drug problems in adolescents. It will take timeand further research efforts to determine which of thestrategies, if any, are superior to the others in reducingalcohol and drug problems in adolescents. Some pro-grams have been evaluated more extensively than others;for example, the D.A.R.E. program recently underwent anextensive number of evaluative studies that have generallyconcluded that the program has limited success. West andO'Neal (2004) conducted a meta-analysis by examiningthe results of several studies of the effectiveness of ProjectD.A.R.E. in preventing alcohol, tobacco, and illicit druguse among school-age youths. They concluded that theeffects of the program were extremely small, indicatingthat D.A.R.E. is ineffective at influencing adolescents tostay away from alcohol and drug use.

Indicated intervention emphasizes the early detection andprompt treatment of maladaptive behavior in a person'sfamily and community setting. In some cases-for exam-ple, in a crisis or after a disaster (Garakina, Hirschowitz, &Katz 2004) (see the discussion on crisis intervention inChapter 5)-indiciited prevention involves immediate andrelatively brief intervention to prevent any long-termbehavioral consequences (Raphael & Wooding, 2004).

The Mental Hospital as aTherapeutic CommunityIn cases where individuals might be considered dangerousto themselves or others (Richards, Smith, et al., 1997) orwhere their symptoms are so severe that they are unable tocare for themselves in the community, psychiatric hospi-talization may be required. Most of the traditional forms oftherapy that we discussed in Chapter 17 may, of course, beused in a hospital setting. In addition, in many mental hos-pitals, these techniques are being supplemented by effortsto make the hospital environment itself a "therapeuticcommunity" (Kennard, 2004; Whiteley, 1991). That is, allthe ongoing activities of the hospital are brought into thetotal treatment program, and the environment, or milieu,is a crucial aspect of the therapy. This approach is thusoften referred to as "milieu therapy" (Kennard, 2000;Zimmerman, 2004). Three general therapeutic principlesguide this approach to treatment:

1. Staff expectations are clearly communicated topatients. Both positive and negative feedback areused to encourage appropriate verbalizations andactions by patients.

2. Patients are encouraged to become involved in alldecisions made, and in all actions taken, concerningthem. A self-care, do-it-yourself attitude prevails.

3. All patients belong to social groups on the ward.The group cohesiveness that results gives the patientssupport and encouragement, and the related processof group pressure helps shape their behavior inpositive ways.

In a therapeutic community, as few restraints as possi-ble are placed on patients' freedom, and patients areencouraged to take responsibility for their behavior andparticipate actively in their treatment programs. Openwards permit patients to use the grounds and premises.

Self-government programs give patients responsibility formanaging their own affairs and those of the ward. All hos-pital personnel are expected to treat the patients as humanbeings who merit consideration and courtesy. The interac-tion among patients-whether in group therapy sessions,social events, or other activities-is planned in such a wayas to be of therapeutic benefit. In fact, it is becoming appar-ent that often the most beneficial aspect of a therapeuticcommunity is the interaction among the patients them-selves. Differences in social roles and backgrounds maymake empathy between staff and patients difficult, but fel-low patients have been there-they have had similar prob-lems and breakdowns and have experienced the anxietyand humiliation of being labeled "mentally ill" and beinghospitalized. Constructive relationships frequently developamong patients in a supportive, encouraging milieu.

Another successful method for helping patients takeincreased responsibility for their own behavior is the use ofsocial-learning programs. Such programs normally makeuse of learning principles and techniques such as tokeneconomies (see Chapter 17) to shape more socially accept-able behavior (Corrigan, 1995, 1997; Mariotto, Paul, &Licht, 2002; Paul, Stuve, & Cross, 1997).

A persistent concern about hospitalization is that themental hospital may become a permanent refuge from theworld. Over the past three decades, considerable effort hasbeen devoted to reducing the population of inpatients byclosing hospitals and treating patients who have mentaldisorders as outpatients. This effort, which is often referredto as deinstitutionalization, was initiated to prevent thenegative effects, for many psychiatric patients, of beingconfined to a mental hospital for long periods of time aswell as to lower health care costs. To keep the focus onreturning patients to the community and on preventingtheir return to the institution, contemporary hospitalstaffs try to establish close ties with patients' families andcommunities and to provide them with positive expecta-tions about the patient's recovery.

The rise of the biological therapies described inChapter 17 has meant that between 70 and 90 percent ofpatients labeled as "psychotic" and admitted to mentalhospitals can now be discharged within a few weeks, or atmost a few months. Recent estimates suggest that there aresome 2 to 3 million chronically mentally ill individuals inAmerica, of whom about half reside in mental hospitalsand the other half in nursing homes or in the community(Regier et al., 1993).

Even where disorders have become chronic, effectivetreatment methods have been developed. In one of themost extensive and well-controlled studies of chronic hos-pitalized patients, Paul and Lentz (1977) compared the rel-ative effectiveness of three treatment approaches:

1. Milieu therapy, focused on structuring a patient'senvironment to provide clear communication ofexpectations and to get the patient involved in the

treatment and participating in the therapeuticcommunity through the group process.

2. A social-learning treatment program, organizedaround learning principles and using a rigorouslyprogrammed token economy system, with ward staffas reinforcing agents. Undesirable behavior was notreinforced, whereas the accumulation of manytokens through effective functioning made a patienteligible for attractive amenities not normallyavailable in public mental hospitals.

3. Traditional mental hospital treatments includingpharmacotherapy, occupational therapy, recreationaltherapy, activity therapy, and individual or grouptherapy. No systematic application of milieu therapyor the social-learning program was given to this group.

The treatment project covered a period of 6 years: aninitial phase of staff training, patient assessment, and base-line recording; a treatment phase; an aftercare phase; and along (year and a half) follow-up. The changes targetedincluded resocialization, learning new roles, and reducingor eliminating bizarre behavior. There were 28 chronicschizophrenic patients in each treatment group, matchedfor age, sex, socioeconomic level, symptoms, and durationof hospitalization. The results of the study were impres-sive. Both milieu therapy and the social-learning programproduced significant improvement in overall functioningand resulted in more successful hospital releases than thetraditional hospital care. The behaviorally based social-learning program, however, was clearly superior to themore diffuse program of milieu therapy, as evidenced bythe fact that over 90 percent of the released patients fromthe social-learning program remained continuously in thecommunity, compared with 70 percent of the releasedpatients who had had milieu therapy. The figure for thetraditional treatment program was less than 50 percent.

Despite the promise of the token economy approach,emulating as it does certain "real-world" principles ofexchange that the patient will face outside the institution,it has not enjoyed wide public acceptance (Paul & Lentz,1977). Many feel that it is cruel and inhumane to expectmental patients to govern their behavior in accordancewith a prescribed schedule of reinforcements. One mightask, however, whether it is more humane to consign thepatient to the status of a passive and helpless recipient ofwhatever the environment has to offer, which in manyinstitutional settings is not very much. Is that truly themessage we want to convey about the patient's relationshipto his or her environment? Probably not, especially in lightof the considerable evidence that most chronic mentalpatients are surprisingly adept at making successful adap-tations that are within their range of control.

AFTERCARE PROGRAMS Even where hospitalizationhas successfully modified maladaptive behavior and apatient has learned needed occupational and interpersonal

skills, readjustment in the community following releasemay still be difficult (Seidman, 2003; Thornicraft &Tansella, 2000). Many studies have shown that in the past,up to 45 percent of schizophrenic patients have beenreadmitted within the first year after their discharge.Community-based treatment programs, now referred to as"aftercare programs," are live-in facilities that serve as ahome base for former patients as they make the transitionback to adequate functioning in the community. Typically,community-based facilities are run not by professionalmental health personnel but by the residents themselves.Aftercare programs can help smooth the transition frominstitutional to community life and reduce the number ofrelapses. However, some individuals do not function wellin aftercare programs. Owen, Rutherford, Jones, and col-leagues (1997) found that clients who were likely to holdunskilled employment, to be nonpsychotic, to have com-mitted a crime, or to be more transient tended to benoncompliant in aftercare programs. The investigatorsconcluded that many of the discharged patients did not"fit" the services typically offered to released psychiatricinpatients. Those with less severe symptoms may failbecause they appear to aftercare staff as not needing muchhelp; most services are geared to those patients who exhibitmore extreme symptoms.

Sometimes aftercare includes a "halfway" period inwhich a released patient makes a gradual return to the out-side world in what were formerly termed "halfway houses."

Aftercare facilities do not a/ways provide the safe refuge promised.I-Iomeless people often live In large cities under austereconditions, noted in this photograph, that resemble those seen inback wards of mental institutions several decades ago.

Aftercare programs do not always live up to their name,however. Levy and Kershaw (2001) disclosed a number ofproblems in which relevant treatment was not made avail-able and staff did not provide a secure environment.

Although some patients continue to have mentalhealth problems including suicide attempts (Fenton,McGlashan, et al., 1997), and many have trouble gainingthe acceptance and support of the community (Fair-weather, 1994; Seidman, 2003), efforts to treat severelydisturbed patients in the community are often very suc-cessful. However, as Dennes (1974) pointed out in the earlyyears of the growth of community-based treatment, itssuccess depends on educational and other social measuresdirected toward increasing community understanding,acceptance, and tolerance of troubled people who may dif-fer somewhat from community norms.

The population of psychiatric patients in the United Stateshas shrunk considerably over the past 35 years. Between1970 and 1992, the number of state mental hospitalsdropped from 310 to 273, and the patient population wasreduced by 73 percent (Witkin, Atay, & Manderscheid,1998). The deinstitutionalization movement has not beenlimited to the United States. On the contrary, there hasbeen a worldwide trend to shift the care of mental patientsfrom inpatient hospitals to community-based programs(D'Avanzo, Barbato, et al., 2003; Emerson, 2004; Honko-nen, Karlsson, et al., 2003; Pijl, Kluiter, & Wiersma, 2001).

Deinstitutionalization-the movement to close downmental hospitals and to treat persons with severe mentaldisorders in the community-has been a source of consid-erable controversy. Some authorities consider the emptyingof the mental hospitals a positive expression of society'sdesire to free previously confined persons and maintain thatdeinstitutionalized patients show significant improvementcompared with those who remain hospitalized (Newton,Rosen, et al., 2000; Reinharz, Lesage, & Contandriopoulos,2000), but others speak of the "abandonment" of chronicpatients to a cruel and harsh existence, which for manyincludes homelessness, violent victimization (Walsh,Moran, et al., 2003), or suicide (Goldney, 2003). Many citi-zens, too, complain of being harassed, intimidated, andfrightened by obviously disturbed persons wandering thestreets of their neighborhoods.

Some of the reduction in mental health services overthe past 25 years has come about because of changes in thehealth care system. (See the Unresolved Issues section atthe end of this chapter.) The planned community efforts tofill the gaps in service never really materialized at effectivelevels (Lamb, 1998).

The number of patients residing in state and countymental hospitals sank from over half a million in 1950(Lerman, 1981) to about 100,000 in the 1990s (Narrowet al., 1993); these figures are even more staggering when

we consider that at the same time, the u.s. population grewby nearly 100 million. A number of factors have interactedto alter the pattern of mental hospital admissions and dis-charges over the past 40 years. Antipsychotic drugs havemade it possible for many patients who would otherwisehave required confinement to live in the community, butnot all mental health problems can be managed with med-ication. In addition, changing treatment philosophy andthe desire to eliminate mental institutions were bolsteredby the assumption that society wanted and could afford toprovide better community-based care for chronic patientsoutside of large mental hospitals.

In theory, closing the public mental hospitals seemedworkable. The plan was to open many community-basedmental health centers that would provide continuing careto the residents of hospitals after discharge. Residentswould be given welfare funds (supposedly at less cost tothe government than maintaining large mental hospitals)and would be administered medication to keep them sta-bilized until they could obtain continuing care. Manypatients would be discharged to home and family; otherswould be placed in smaller, home-like board-and-carefacilities or nursing homes.

Unforeseen problems arose, however, and in manycases, homeless shelters in metropolitan communities havebecome a "makeshift alternative" to inpatient mentalhealth care (Haugland, Sigel, et aI., 1997). Many residentsof mental institutions had no families or homes to go to;board-and-care facilities were often substandard; and thecommunity mental health centers were ill prepared andinsufficiently funded to provide needed services forchronic patients, particularly as national funding prioritiesshifted during the 1980s (Humphreys & Rappaport, 1993).Many patients had not been carefully selected for dischargeand were not ready for community living, and many ofthose who were discharged were not followed up suffi-cientlyor often enough to ensure their successful adapta-tion outside the hospital.

One recent court case (Albright v. Abington MemorialHospital, 1997) involved charges that the hospital failed toprovide sufficient care for a seriously disturbed womanwho later killed herself. Countless patients have been dis-charged to fates harsher than the conditions in any of thehospitals (Westermeyer, 1987). The following case illus-trates the situation.

Dave B., 49 years old, had been hospitalized for 25 yearsin a state mental hospital. When the hospital was sched-uled for phaseout, many of the patients, particularly

those who were regressed or aggressive, were trans-ferred to another state hospital. Dave was a borderlinementally retarded man who had periodic episodes of psy-chosis. At the time of hospital closing, however, he wasnot hallucinating and was "reasonably intact." Dave wasconsidered to be one of the "less disturbed" residentsbecause his psychotic behavior was less pronounced andhe presented no dangerous problems. Hewas dischargedto a board-and-care facility (actually an old hotel wheremost of the residents were former inpatients). At first,Dave seemed to fit in well at the facility; mostly he sat inhis room or in the outside hallway, and he caused no trou-ble for the caretakers. Two weeks after he arrived, hewandered off the hotel grounds and was missing for sev-eral days. The police eventually found him living in thecity dump. He had apparently stopped taking his medica-tion, and when he was discovered he was regressed andcatatonic. Hewas readmitted to a state hospital.

Recent research on the effects of deinstitutionalizationhas been mixed. Some reports have noted positive benefitsof briefer hospitalization (Honkonen, et aI., 2003; Rauktis,2001), and some data suggest that deinstitutionalizationappears not to be associated with an increased risk ofhomicide by people who are mentally ill (Simpson,McKenna, et aI., 2004). However, others have reportedproblems with discharged patients and point to failures inprograms to deinstitutionalize mental patients (Chan,Ungvari, & Leung, 2001; Leff, 2001).

There has been recent indication that inpatient psy-chiatric hospitalization may be increasing because of thefailures to provide adequate mental health care for patientsin need of mental health services in the community (Mar-cotty, 2004). A similar increase in the number of peoplebeing hospitalized has been reported in the United King-dom (Priebe & Turner, 2003).

HOMELESSNESS By the early 1980s, cases like Dave'shad become commonplace in large cities throughout thenation. Vagrants and "bag ladies" appeared in abundanceon city streets and in transport terminals, and the virtuallyalways overwhelmed shelters for homeless persons hastilyexpanded in futile efforts to contain the tide of recentlydischarged patients. Street crime soared, as did the deathrate among these hapless persons, who lacked survivalresources for the harsh urban environment.

The full extent of problems created by deinstitution-alization is not precisely known, partly because there hasbeen little rigorous follow-up on patients dischargedfrom mental hospitals. Such research investigations aredifficult to conduct because the patients are transient andhard to keep track of over time. Certainly, not all home-less people are former mental patients, but deinstitution-alization has contributed substantially to the number of

18.2

The number of people with mental disorders inprison populations is alarming (Lamb & Wein-berger, 1998). According to recent JusticeDepartment statistics, over 16 percent of thepeople in prison in the United States

(275,000) have a diagnosed mental disorder. Mentally illpersons who are evaluated in jails or prisons are twice aslikely to have been homeless before their arrest. More-over, mentally ill inmates tend to have more incarcerationsthan other prisoners, and more than three-quarters ofthem have been sentenced to jail or prison in the past. Themodern trend of using prisons and jails as facilities tohouse mentally ill persons is, of course, not a new concept(Torrey, 1997). About 150 years ago, the great socialreformer Dorothea Dix became concerned over the largenumber of mentally ill people confined to prisons and jailsand launched a movement to develop mental hospitals toprovide more humane treatment for them. Gilligen (2001)recently noted that public mental hospitals were createdbecause many mentally ill people were being held in pris-ons or jails. Over time, support for those hospitals hasdiminished, and by the time they had degenerated intoproblem facilities a consensus was reached to close themdown. However, they have not been replaced with ade-quate community mental health resources to treatseverely disturbed patients. As the hospitals have emp-

homeless people (Lamb, 1998) and to the number ofmentally ill people in prison (Butterfield, 1998; Powellet al., 1997), as described in The World Around Us 18.2.

In ReVIew••. What are some strategies for biological,

psychosocial, and sociocultural universalinterventions?

••. Define the term selective intervention. Whatselective intervention programs have shownpromise in helping prevent teenage alcoholand drug abuse?

••. What is indicated intervention?••. What problems have resulted from

d~institutionalization ?

Jails and Prisons: Serving asMental Hospitals Again

tied, the prisons and jails have begun to fill, partly withthe mentally ill.

As a result of deinstitutionalization over the past 20

years and the subsequent closing of so many psychiatricfacilities, there are fewer places where mentally ill patientscan receive inpatient treatment. Moreover, there has beeninsufficient development of community-based services toprovide outpatient care for people who need it. Conse-quently, many people become homeless because they can-not take care of themselves or because they commit crimesas a result of their uncontrolled behavior.

The high rates of psychiatrically disturbed persons inprisons and jails are a problem not only in the UnitedStates but in other countries as well (Bluglass, 2000). Arecent study of prison inmates in 13 European countriesreported similar high rates of mental disorder in the inmatepopulation and indicated that countries differ widely inhow they deal with the mentally disordered inmate(Blaauw, Roesch, & Kerkhof, 2000; see also Birmingham,Gray, Mason, & Grubin, 2000). Comparably high rates ofmental disorder in prisons have recently been reported inNew Zealand as well (Brinded et aI., 1999).

Do mentally ill men and women who are incarceratedactually receive mental health treatment? A recent surveyby the U.S. Department of Justice reported that 1.394 ofthe nation's public and private adult correctional facilities

CONTROVERSIALLEGAL ISSUES AND THEMENTALLY DISORDERED ~_.A number of important issues are related to the legal statusof mentally ill people-the subject matter of forensic psy-chology or forensic psychiatry-and they center on therights of patients and the rights of members of society tobe protected from disturbed individuals. For a survey ofsome of the legal rights that mentally ill people have gainedover the years, see The World Around Us 18.3 on page 654.

Persons with psychological problems or behaviors that areso extreme and severe as to pose a threat to themselves orothers may require protective confinement. Those whocommit crimes, whether or not they have a psychologicaldisorder, are dealt with primarily through the judicial sys-

provide mental health servicesto inmates. Almost 70 percent ofthe facilities that reportedscreen inmates when they areincarcerated, and 65 percentconduct some type of psychiatricexamination. Inaddition, 51 per-cent of these facilities providearound-the-clock mental healthservices, but only 2 percent ofthe prison population live in a24-hour treatment unit. The sur-vey showed that 71percent ofthe facilities provide counselingand 73 percent distribute med-ications to inmates (Beck& Mar-uschak, 2001). However, manyauthorities have reported thatmental health services are typi-callynot provided for the major-ity of inmates who require them(Gilligen,2001).Teplin,Abram,and McClelland(1997)reportedthat only 23.5 percent of thewomen who needed mentalhealth services received themwhile they were in jail, despitethe fact that 80 percent of thesample met criteria for a lifetimemental disorder.

In the United States and Canada jails and prisons are extremely overcrowded andunable to implement rehabilitation efforts for those imprisoned. Inmates aretypically at great risk of developing further problems such as aggression, illness,mental health problems, higher suicide rates, and increased likelihood of recidivism.

tem-arrest, court trial, and, if convicted, possible con-finement in a penal institution. People who are judged tobe potentially dangerous because of their psychologicalstate may, after civil commitment procedures, be confinedin a mental institution. The steps in the commitmentprocess vary slightly depending on state law, the locallyavailable community mental health resources, and thenature of the problem. For example, commitment proce-dures for a mentally retarded person are different fromthose for a person whose problem is alcohol abuse.

There is a distinction between voluntary hospitaliza-tion and involuntary commitment. In most cases, peopleaccept voluntary commitment or hospitalization. In thesecases, they can, with sufficient notice, leave the hospital ifthey wish. But in cases where a person may be considereddangerous or is unable to provide for his or her own care,the need for involuntary commitment may arise (Zerman& Schwartz, 1998).

A person's being mentally ill is not sufficient groundsfor placing that person in a mental institution against hisor her will. Although procedures vary somewhat from state

to state, several conditions beyond mental illness usuallymust be met before formal involuntary commitment canoccur (Simon & Aaronson, 1988). In brief, such individu-als must be judged to be

Dangerous to themselves or to others and/orIncapable of providing for their basic physical needsand/orUnable to make responsible decisions abouthospitalization andIn need of treatment or care in a hospital

Typically, filing a petition for a commitment hearing isthe first step in the process of committing a person invol-untarily. This petition is usually filed by a concerned indi-vidual such as a relative, physician, or mental healthprofessional. When such a petition is filed, a judge appointstwo examiners to evaluate the "proposed patient." In Min-nesota, for example, one examiner must be a physician (notnecessarily a psychiatrist); the other can be a psychiatrist ora psychologist. The patient is asked to appear voluntarily

18.3

Several important court decisions have helpedestablish certain basic rights for individualssuffering from mental disorders. But they havealso curtailed these rights, amid continuingcontroversy.

~ Right to treatment. In 1972 a U.S. district court inAlabama rendered a landmark decision in the case ofWyatt v. Stickney. It ruled that a mentally ill or men-tally retarded person had a right to receive treatment.Since the decision, the state of Alabama hasincreased its budget for the treatment of mental ill-ness and mental retardation by 300 percent (seeWinick,1997).

~ Freedom from custodial confinement. In 1975the U.s. Supreme Court upheld the principle thatpatients have a right to freedom from custodial con-finement if they are not dangerous to themselves orothers and if they can safely survive outside of cus-tody. In Donaldson v. O'Connor, the defendants wererequired to pay Donaldson $10,000 for having kepthim in custody without providing treatment.

~ Right to compensation for work. In 1973 a U.s.District Court ruled in the case of Souderv. Brennan(the secretary of labor) that a patient in a nonfederalmental institution who performed work must be paidaccording to the Fair Labor Standards Act. Although a1978 Supreme Court ruling nullified the part of thelower court's decision dealing with state hospitals,the ruling still applied to mentally ill and mentallyretarded patients in private facilities.

~ Right to live in a community. In 1974 a U.S. dis-trict court decided, in the case of Staffv. Miller, that

Important Court Decisionsfor Patient Rights

released state mental hospital patients had a right tolive in "adult homes" in the community.

~ Right to less restrictive treatment. In 1975 aU.S. district court issued a landmark decision in thecase of Dixon v. Weinberger. The ruling establishedthe right of individuals to receive treatment in lessrestrictive facilities than mental institutions.

~ Right to legal counsel at commitment hearings.The state Supreme Court of Wisconsin decided in1976, in the case of Memme/ v. Mundy, that an individ-ual had the right to legal counsel during the commit-ment process.

~ Right to refuse treatment. Several court deci-sions have provided rulings, and some states haveenacted legislation, permitting patients to refuse cer-tain treatments such as electroconvulsive therapy andpsychosurgery.

~ The need for confinement must be shown byclear, convincing evidence. In 1979 the U.S.Supreme Court ruled, in the case of Addington v.Texas, that a person's need to be kept in an institutionmust be based on demonstrable evidence.

~ Limitation on patients' rights to refuse psy-chotropic medication. In 1990 the U.s. SupremeCourt ruled, in Washington v. Harper, that a Washing-ton State prison could override a disturbed prisoner'srefusal of psychotropic medications. This decisionwas based on a finding that the prison's reviewprocess adequately protected the patient's rights. Wesee in this instance that changes in the national politi-cal climate can reverse prior trends that favoredpatients'rights.

for psychiatric examination before the commitment hear-ing. The hearing must be held within 14 days, which can beextended for 30 more days if good cause for the extensioncan be shown. The law requires that the court-appointedexaminers interview the patient before the hearing.

When a person is committed to a mental hospital fortreatment, the hospital must report to the court within 60days on whether the person needs to be confined evenlonger. If the hospital gives no report, the patient must bereleased. If the hospital indicates that the person needs fur-ther treatment, then the commitment period becomesindeterminate, subject to periodic reevaluations.

Because the decision to commit a person is based onthe conclusions of others about the person's capabilitiesand his or her potential for dangerous behavior, the civilcommitment process leaves open the possibility of theunwarranted violation of a person's civil rights. As a conse-quence, most states have stringent safeguards to ensurethat any person who is the subject of a petition for com-mitment is granted due process, including rights to formalhearings with representation by legal counsel. If there is

not time to get a court order for commitment or if thereis imminent danger, however, the law allows emergencyhospitalization without a formal commitment hearing. In

such cases, a physician must sign a statement saying that animminent danger exists. The patient can then be picked up(usually by the police) and detained under a "hold order;'usually not to exceed 72 hours, unless a petition for com-mitment is filed within that period.

Involuntary commitment in a psychiatric facility islargely contingent on a determination that a person is dan-gerous and requires confinement out of a need to protecthimself or herself or society. Once committed, a patientmay refuse treatment-a situation that not infrequentlyconfronts mental health professionals working in psychi-atric facilities (Grisso & Appelbaum, 1998). We will nowturn to the important question of evaluating patients interms of potential dangerousness.

Assessment 'of "Dangerousness"As we have seen, although most psychiatric patients arenot considered dangerous, some are violent and requireclose supervision-perhaps confinement until they are nolonger dangerous. Few psychiatric patients are assaultiveat or prior to their admission to psychiatric facilities.Rates of assaultiveness vary from setting to setting, but inall reported studies, the overall number of assaultivepatients is relatively low. A history of violent behavior(Bonta et aI., 1998) and some classes of mental disorderappear to be associated with violence, as an increasingnumber of clinical researchers in recent years have discov-ered (Pinard & Pagani, 2001). Although most disorderedpeople show no tendency toward violence (Lamberg,1998), an increased risk of violence appears more likelyamong some who are experiencing psychotic symptoms(Hodgins & Lalonde, 1999; Tardiff, 1998). The disordersthat have an increased risk for violent behavior includeschizophrenia, mania, personality disorder, substanceabuse, and the more rare conditions of organic braininjury and Huntington's disease. One study from Finland(Eronen, Hakola, & Tiihonen, 1996) reported that homici-dal behavior among former patients was considerablymore frequent among schizophrenics and even more com-mon among patients with antisocial personality or alco-holism. Psychiatric patients who abuse alcohol (Steadman,Mulvey, et aI., 1998) were found to be notably violent.

Practitioners are often called upon to evaluate thepossibility that a patient might be dangerous, and there issome evidence that mental health professionals can con-tribute to such an assessment (Monahan, Steadman, et aI.,2001; Steadman, 2000; Szmukler, 2001), at least on a short-term basis (Binder, 1999). The determination that a patientis potentially dangerous can be difficult to make (Bauer,Rosca, et aI., 2003; Heilbrun, 1997; Rogers, 2000), yet this isone of the most important responsibilities of professionalsworking in the field of law and psychology. A clinician hasa clear responsibility to try to protect the public frompotential violence or other uncontrolled behavior of dan-gerous patients. A dramatic incident of a failure to assess

the extent of a patient's dangerousness was reported byGorin (1980, 1982) on the television news program60 Minutes:

Case of violent domestic abuse. In December, 1979,Mrs. EvaB.was brutally stabbed to death by her formerhusband while a police dispatcher listened to her terri-fied screams over the telephone. Only hours before thestabbing incident occurred, Mr. B.,who had attackedMrs. B.eight times in the past, had been judged by twostaff psychiatrists not to be dangerous. He had then beenreleased, as part of his treatment, on a temporary passfrom the Pilgrim State Hospital in New York.The hospi-tal staff had released Mr. B. from confinement at thistime despite the fact that both the judge and the prose-cuting attorney who had been involved in his trial (forattempting to kill his wife) had independently writtenthe New YorkState Department of Mental Health rec-ommending that Mr. B.be held in the strictest confine-ment because of his persistent threats against Mrs. B.(Indeed, on two previous occasions, Mr. B.had escapedfrom the hospital and attempted to kill her.) The judgeand attorney had also recommended that Mrs. B. shouldbe warned if Mr. B.was released. Ironically, six hoursafter she had been murdered, a telegram from the hospi-tal was delivered to Mrs. B.'shome warning her that herhusband had not returned from his pass.

Looking beyond whatappears to be some failureto follow through on thecourt's recommendations,this case illustrates a num-ber of difficult yet criticaldilemmas involved in try-ing to identify or predictdangerousness in psychi-atric patients. First, itemphasizes the fact thatsome people are capableof uncontrolled violentbehavior and hence arepotentially dangerous ifleft unsupervised in thecommunity. It also reflectsthe dilemma faced by men-tal health professionals,who, attempting to reha-bilitate disturbed patientsby gradually easing themback into society, mustplace some degree of trustin these individuals. Finally,and critically, it illustratesthat it is very difficult-forprofessionals and laypersons alike-to accurately appraise"dangerousness" in some individuals.

Predicting who will become violent isvery difficult. Mental healthprofessionals typically err on theconservative side, considering somepatients as more violence prone thanthey actually are. At the same time, theyhave an obligation to integratedisordered individuals back into society,a move that has occasionally met withtragic results.

ATTEMPTS TO PREDICT DANGEROUSNESS The com-plex problem of risk assessment or prediction of danger-ousness can be likened to predicting the weather."Ultimately, the goal of a warning system in mental healthlaw is the same as the goal of a warning system in meteor-ology: to maximize the number of people who take appro-priate and timely actions for the safety of life andproperty" (Monahan & Steadman, 1997, p. 937).

It is usually easy to determine, after the fact, that a per-son has demonstrated dangerous behavior but how well domental health professionals do in predicting the occur-rence of dangerous acts? Not as well as we would like(Edens, Buffington-Vollum, et aI., 2005). Violent acts areparticularly difficult to predict because they are apparentlydetermined as much by situational circumstances (forexample, whether a person is under the influence of alco-hol) as by an individual's personality traits or violent pre-dispositions. One obvious and significantly predictive riskfactor is a past history of violence (Megargee, 2002), butclinicians are not always able to unearth this type of back-ground information.

As already noted, some types of patients, particularlyactively schizophrenic and manic individuals (Hodgins &Lalonde, 1999) and patients with well-entrenched delu-sions (de Pauw & Szulecka, 1988), are far more likely thanothers to commit violent acts. Martell and Dietz (1992)reported a study of persons convicted of pushing orattempting to push unsuspecting victims in front of NewYork City subway trains and found that most were bothpsychotic and homeless at the time of the act. Norko &Baranoski (2005) noted that although many studies pointto a modest increased risk of violence associated withmental illness, particularly psychosis, other studies havenot confirmed these findings.

Mental health professionals typically overpredict vio-lence. They consider some individuals more dangerousthan they actually are and usually predict a greater per-centage of clients to be dangerous than actually becomeinvolved in violent acts (Megargee, 2002). Such a tendencyis of course understandable from the perspective of thepractitioner, considering the potentially serious conse-quences of releasing a violent individual. It is likely, how-ever, that many innocent patients thereby experience aviolation of their civil rights. Given a certain irreduciblelevel of uncertainty in the prediction of violence, it is notobvious how this dilemma can be completely resolved.

THE DUTY TO PROTECT: IMPLICATIONS OF THE TARA-SOFF DECISION What should a therapist do uponlearning that a patient is planning to harm another person?Can the therapist violate the legally sanctioned confidenceof the therapy contract and take action to prevent thepatient from committing the act? Today, in most states,the therapist not only can violate confidentiality withimpunity but may be required by law to take action to pro-

tect people from the threat of imminent violence againstthem. In its original form, this requirement was conceivedas a duty to warn the prospective victim.

The duty-to-warn legal doctrine was given greatimpetus in a California court ruling in 1976 in the case ofTarasoff v. Regents of the University of California et al.(Mills, Sullivan, & Eth, 1987). In this case, Prosenjit Poddarwas being seen in outpatient psychotherapy by a psycholo-gist at the university mental health facility. During histreatment, Mr. Poddar indicated that he intended to kill hisformer girlfriend, Tatiana Tarasoff, when she returnedfrom vacation. Concerned about the threat, the psycholo-gist discussed the case with his supervisors, and theyagreed that Poddar was dangerous and should be commit-ted for further observation and treatment. They informedthe campus police, who picked up Poddar for questioning,subsequently judged him to be rational, and released himafter he promised to leave Ms. Tarasoff alone. Poddar thenterminated treatment with the psychologist. About 2months thereafter, he stabbed Ms. Tarasoff to death. Herparents later sued the University of California and staffmembers involved in the case for their failure to hospital-ize Poddar and their failure to warn Tarasoff about thethreat to her life. In due course, the California SupremeCourt in 1974 ruled that the defendants were not liable forfailing to hospitalize Poddar; it did, however, find themliable for failing to warn the victim. Ironically, ProsenjitPoddar, the criminal, was released on a trial technicalityand returned home to India. In a later analysis of the case,Knapp (1980) said that the court ruled that difficulty indetermining dangerousness does not exempt a psychother-apist from attempting to protect others when a determina-tion of dangerousness exists. The court acknowledged thatconfidentiality was important to the psychotherapeuticrelationship but stated that the protection privilege endswhere public peril begins.

The duty-to-warn ruling-which has come to beknown as the Tarasoff decision-spelled out a therapist'sresponsibility in situations where there has been an explicitthreat on a specific person's life, but it left other areas ofapplication unclear. For example, does this ruling apply incases where a patient threatens to commit suicide, andhow might the therapist's responsibility be met in such acase?What, if anything, should a therapist do when the tar-get of violence is not clearly named-for example, whenglobal threats are made? Would the duty-to-warn rulinghold up in other states? Or might deleterious effects onpatient-therapist relationships outweigh any public bene-fit to be derived from the duty to warn? Responding tomounting pressures for clarification, chiefly from mentalhealth professional organizations, the California SupremeCourt in 1976 issued a revised opinion called the "duty towarn doctrine." In this decision the Court ruled that theduty was to protect, rather than specifically to warn, theprospective victim, but it left vague the question of how

this duty might be discharged-presumably in order togive practitioners latitude in dealing with danger to thirdparties. Meanwhile, however, numerous other lawsuits inother jurisdictions have been filed and adjudicated ininconsistent and confusing ways (Mills et aI., 1987).

The many perplexing issues for practitioners left in thewake of Tarasoff were partly resolved, at least in California,by the legislature's adoption in 1985 of a new state lawessentially establishing that the duty to protect is dischargedif the therapist makes "reasonable efforts" to inform poten-tial victims and an appropriate law enforcement agency ofthe pending threat. In other jurisdictions, however, theinconsistent judicial fallout from Tarasoff has continuedand has been a source of much anxiety and confusionamong mental health professionals, many of whom con-tinue to believe, on ethical and clinical grounds, that strictconfidentiality is an absolute and inviolable trust. A smallminority of states-for example, Maryland and Pennsylva-nia-have explicitly affirmed that position, abandoningTarasoff altogether (Mills et aI., 1987) while 23 statesimpose a duty to warn but the criteria for this typicallyvaries (Herbert, 2002). Some states have tended to limit theapplicability of the duty to warn (Walcott, Cerundolo, &Beck, 2001), while one recent court decision (Ewing v.Goldstein, 2004) actually extended the ruling to include aneed to warn when the therapist did not hear the threatfrom the patient but from a family member who communi-cated to the therapist that the patient had made a threat.

Official professional ethics codes, such as that of theAmerican Psychological Association (2002), normallycompel compliance with relevant laws regardless of one'spersonal predilections. Where the law is itself vague orequivocal, however, as it often is in this area, there ismuch room for individual interpretation (Kachigian &Felthous,2004).

The Insanity DefenseSome people who are being tried for murder use theinsanity defense-also known as the NGRI plea ("notguilty by reason of insanity")-in an attempt to escape thelegally prescribed consequences of their crimes. Thesedefendants claim that they were not legally responsible fortheir criminal acts. In technical legal terms, they invokethe ancient doctrine that their acts, while guilty ones(actus rea), lacked moral blameworthiness because theywere not intentional since the defendants did not possesstheir full mental faculties at the time of the crime and didnot "know what they were doing" (mens rea)-the under-lying assumption being that "insanity" somehow precludesor absolves the harboring of a guilty intent. (See The WorldAround Us 18.4. on p. 658.) One of the most notorioususes of the Not Guilty by Reason of Insanity plea in Amer-ican history was in the case of Jeffrey Dahmer, on trial forthe murder, dismemberment, and cannibalization of 15

Jeffrey Dahmer was torturing and drowning cats and dogs byage 7. He never heard voices or broke with reality. He tricked hisvictims into being handcuffed (they thought it was part of a sexualgame) and then dripped acid into their flesh and skulls, renderingthem zombies. Then, he would engage them sexually, and wouldoccasionally cannibalize them. Dahmer was charged with and laterconvicted of murder after body parts of several young men werefound in his apartment. While serving his time in prison, he wasbludgeoned to death by a psychotic killer in 1994.

men in Milwaukee. In the Dahmer case, the planned insan-ity defense proved unsuccessful, which is the usual out-come (Steadman et aI., 1993).

By contrast, attorneys for John Hinckley, who shotPresident Reagan and his press secretary, James Brady,successfully pleaded NGRI. (See the Case Study onp. 658.) The outcome of the Hinckley case was different ina number of important respects, because the jury in thisinstance considered the defendant to be acting "outside ofreason" and found him "not guilty by reason of insanity."At trial in June 1982, Hinckley was acquitted on thosegrounds. This verdict immediately unleashed a storm ofpublic protest and generated widespread, often hastyattempts to reform the law and make the NGRI defense aless attractive option to defendants and their attorneys.Hinckley himself was committed to the care of a federallyoperated, high-security mental hospital, to be involuntar-ily detained there until such time as his disorder remits suf-ficiently that his release would not constitute a danger tohimself or others. He remains incarcerated; however,under a 1999 federal appeals court ruling, Hinckley hasbeen able to take supervised day trips off hospital grounds,and most recently he has requested that he be allowed totravel unescorted to his parents' home in Williamsburg,Virginia, some 3 hours away. However, his "recovery" hasbeen questioned. Recent psychiatric testimony (AssociatedPress, 2003) has indicated that Hinckley still suffers fromthe same narcissistic personality disorder that drove him toshoot Reagan and three others in 1981.

Releasing Hinckley from custody would almost cer-tainly bring forth another public outcry demanding aboli-tion or limitation of the insanity defense. This unfortunate

public outrage at all insanity defense pleas results from apersistent failure of legal scholars to examine critically andrigorously the guilt-absolving insanity construct and themens rea doctrine from which it derives.

Hinckley's SuccessfulInsanity Plea

On March 30, 1981, in anapparent scheme to attractthe attention of actressJodie Foster, with whom hewas obsessed, John Hinck-ley, Jr., shot six bullets atPresident Ronald Reagan inan assassination attempt.President Reagan was seri-ously injured, as was PressSecretary James Brady. Atthe end of his trial in1982, Hinckley was found

not guilty by reason of insanity. Since his trial, Hinckleyhas been confined to St. Elizabeth's Hospital in Washing-ton, DC. After what seemed to be significant improve-ment in his mental health, Hinckley was allowedunsupervised visits in April 2000, but these visits wererevoked when guards discovered a smuggled book onJodie Foster in his room.

18.4

7 f a person commits a capital offense when his orher consciousness (and reason) is impaired, as inan altered state, should he or she be heldresponsible for the crime? Can using psychotropicmedicine such as Prozac or Zoloft "poison" a per-

son's mind to such an extreme degree that she or he com-mits murder? Ifa murder is committed while someone isheavily "sedated" -for example, with Xanax or Halcion-should that person be released from criminal responsibilitybecause he or she was involuntarily intoxicated with medica-tions prescribed by a health professional? Ifa person experi-ences "multiple personalities" and a crime is committed byone personality, should all of the personalities suffer theconsequences? These defense strategies can be interestingand controversial challenges to today's legal system.

In recent years the use of the NGRI defense in trialswhere the defendant's life is at stake has been surroundedby controversy, largely owing to the uproar created by theoutcome of the Hinckley trial (Steadman et al., 1993).Some have contended that the objection to the insanitydefense in capital crimes might reflect negative social atti-tudes toward the insane (Perlin, 1996). There has beensome concern, especially in cases of high visibility, thatguilty defendants may feign mental disorder and henceavoid criminal responsibility. Good defense attorneys areof course aware of this public cynicism, which is likely tobe shared by juries. They attempt to counteract it in vari-ous ways, often by portraying their purportedly "insane atthe time of the act" clients as having been themselves vic-tims of heinous and traumatic acts at an earlier time intheir lives. Some of them undoubtedly were victimized,but the strategy of creating sympathy while offering a plau-sible explanation for the "insane" act would have a com-pelling attraction in any case. On the other hand, theinsanity defense is often not employed where it is appro-priate, as it would have been, for example, in two high-visibility cases: those of John Salvi (the abortion clinicassassin) and Theodore Kaczynski (the Unabomber).Apparently neither defendant wanted his mental state tobe a part of the proceedings. Severe delusional disorder(see Chapter 14) is likely to have played a significant role inboth of their crimes.

Despite some features that make it an appealingoption to consider, especially where the undisputed factsare strongly aligned against the defendant, the NGRI

Controversial Not Guilty Pleas:CanAltered Mind States orPersonality Disorder LimitResponsibilit for a Criminal Act?

Altered States of ConsciousnessIn a civil trial, the jury failed to find the manufacturer ofProzac (Eli Lilly)liable in court action that resulted from a1989 mass murder allegedly committed "under the influ-ence" of Prozac. The murderer Uoseph Wesbecker), in arage against his employer, killed 8 people and wounded12 others before killing himself. Survivors and family mem-bers of several people who were killed in the incident fileda suit against Eli Lillybecause the company had producedthe drug Prozac, which the killer was taking at the time ofthe murders and which was alleged to be responsible for"intoxicating" the assassin and lowering his inhibitions.After a long trial, the jury found in favor of the manufac-turer (Fentress et 01.v. Shea Communications et 01.,1990).

Courts have generally not considered altered states ofconsciousness such as being intoxicated on drugs or alco-hol sufficient grounds for an insanity defense because ofthe issue of volition-that is, the perpetrator of the crimeconsciously chose to become intoxicated in the first place_However, the question of intoxication by drugs that weretaken for the purpose of medication has added a newdimension to the defense. This issue has not been fullyresolved in the court system.

Altered Personality StatesPossibly the most fascinating of controversial insanity pleasare those raised by the phenomenon of multiple personalitydisorder, now called "dissociative identity disorder" (DID),which has become a more common diagnosis in recentyears. Although some professionals dispute even the exis-tence of such a condition, others find it a plausible argu-ment for a plea of not guilty by reason of insanity (NGRI).

The general nature of the problem can be stated quitesuccinctly: Within a legal system strongly oriented to theprecise identification of individual responsibility for acts,what if any are the limits of the assignment of responsibil-ity and sanctions for infractions of the law where the samephysical space and body are occupied at different times bymore than one distinct and legally recognizable person?Consider the following legal dilemmas:

~ Who, among various co-personalities, is empoweredto sign for withdrawals from a bank account?

~ Are the provisions and obligations of a contractentered into by one constituent personality bindingon all others, regardless of their particular desires inthe matter?

~ Does the swearing of an oath, as in court, apply to theentire collection of personalities, or must each besworn individually if he or she is to testify?

~ In the case of a guilty verdict for the criminal act of agiven personality, where other personalities did notacquiesce in the crime, how should punishment befairly meted out?

~ If no constituent personality meets a test of insanity,is it reasonable and lawful to declare DID itself aninstance of insanity?

~ Has rape occurred if the co-personalities of a 26-year-old woman who had acquiesced to intercourseincluded one or more personalities who vehementlyobjected to it? (Such a case was prosecuted in Wis-consin in 1990.)

~ And, of course, the most common real-life legaldilemma: Should an individual, as the primary person-ality, be held legally accountable for, say, a capital crimethat evidence suggests may have actually been commit-ted surreptitiously, so to speak, by an alter personality?

The scenario just mentioned has rather often beenthe contention underlying a plea of not guilty by reason ofinsanity. Usually, as in the case of the "Hillside Strangler"Kenneth Bianchi (convicted of 12 rapes and murders inCalifornia and Washington State) and in the case of awoman who kidnapped a newborn from a hospital andlater claimed that an alter personality actually committedthe crime (Appelbaum & Greer, 1994), the plea has failed.On a very few occasions, however, the NGRIplea hasworked, as in the well-publicized 1978 case of Ohio resi-dent Billy Milligan, who claimed to be host to ten person-alities and was accused of raping four women (New YorkTimes, 1994). The legal maneuvers inspired by the DIDconstruct admittedly have a quality of whimsy aboutthem. It is consequently difficult to convince most juriesthat the defendant was so taken over by an alter personal-ity who perpetrated the crime that he or she should beabsolved of guilt and responsibility.

defense has actually been employed quite rarely-in lessthan 2 percent of capital cases in the United States overtime (Lymburner & Roesch, 1999; Steadman et aI., 1993).Studies have confirmed, however, that in some jurisdic-tions, persons acquitted of crimes by reason of insanityspend less time, on the whole, in a psychiatric hospital thanpersons who are convicted of crimes spend in prison(Lymburner & Roesch, 1999). In addition, states differwidely in the amount of time that persons found not guiltyby reason of insanity are actually confined. For example,one study by Callahan and Silver (1998) reported that inthe states of Ohio and Maryland, nearly all persons acquit-ted as NGRI have been released within 5 years, whereas inConnecticut and New York, conditional release has beenmuch more difficult to obtain. The re-arrest rates for freed

NGRI claimants vary, with some studies reporting rates ashigh as 50 percent (Callahan & Silver, 1998; Wiederanders,Bromley, & Choate, 1997). Monson, Gunnin, and col-leagues (2001) conducted a follow-up of 125 NGRI acquit-tees and found a similarly high re-arrest rate. Theseinvestigators reported that persons discharged to live withtheir family of origin or to alone/semi-independent livingwere more likely to maintain their conditional release andnot reoffend. These investigators reported that such factorsas minority status, comorbid substance abuse, and priorcriminal history were associated with return to custodyafter release. One recent study in which an active commu-nity treatment program was implemented reported low re-arrest rates (1.4 percent) and moderate rehospitalizationrates (14 percent; Parker, 2004).

Detected Faking of theInsanity Defense

Michael McDermott testified that Michael the Archangelhad sent him on a mission to prevent the Holocaust whenhe gunned down seven co-workers on December 26, 2000.

McDermott also stated that he believed he was soulless,and that by killinghewould earn a soul. McDermottclaimedto have been raped bya neighbor when he was a young boyand had a history of paranoia and suicide attempts. Despitethis claim of insanity, a jury found McDermott guilty in theshooting deaths of his seven co-workers. The prosecutionargued that McDermott was motivated to kill because hisemployer was about to deduct back taxes owed to the IRSfromhiswages. Evidenceseized fromhis computer showedthat McDermotthad researched how to fake being mentallyill. McDermott is currently serving seven consecutive lifesentences for his crimes.

Up to this point in the discussion, we have used theterm insanity defense loosely. We must now become moreattentive to the many precise legal nuances involved.Established precedents that define the insanity defense areas follows:

1. The M'Naghten Rule (1843). Under this ruling,which is often referred to as the "knowing right fromwrong" rule, people are assumed to be sane unless itcan be proved that at the time of committing the act,they were laboring under such a defect of reason(from a disease of the mind) that they did not knowthe nature and quality of the act they were doing-or,if they did know they were committing the act, theydid not know that what they were doing was wrong.

2. The Irresistible Impulse Rule (1887). A secondprecedent in the insanity defense is the doctrine ofthe "irresistible impulse." This view holds thataccused persons might not be responsible for theiracts, even if they knew that what they were doing waswrong (according to the M'Naghten Rule), if theyhad lost the power to choose between right andwrong. That is, they could not avoid doing the act inquestion because they were compelled beyond theirwill to commit the act (Fersch, 1980).

3. The Durham Rule. In 1954, Judge David Bazelon,in a decision of the U.S. Court of Appeals, broadenedthe insanity defense further. Bazelon did not believethat the previous precedents allowed for a sufficientapplication of established scientific knowledge ofmental illness and proposed a test that would bebased on this knowledge. Under this rule, which isoften referred to as the product test, the accused isnot criminally responsible if his or her unlawful actwas the product of mental disease or mental defect.

4. The American Law Institute (ALl) Standard (1962).Often referred to as the "substantial capacity test" forinsanity, this test combines the cognitive aspect ofM'Naghten with the volitional focus of irresistibleimpulse in holding that the perpetrator is not legallyresponsible if at the time of the act he or she, owingto mental disease or defect, lacked "substantialcapacity" either to appreciate its criminal characteror to conform his or her behavior to the law'srequirements.

5. The Federal Insanity Defense Reform Act (IDRA).Adopted by Congress in 1984 as the standard forthe insanity defense to be applied in all federaljurisdictions, this act abolished the volitional elementof the ALl standard and modified the cognitive oneto read "unable to appreciate;' thus bringing thedefinition quite close to M'Naghten. IDRA alsospecified that the mental disorder involved must be asevere one and shifted the burden of proof from theprosecution to the defense. That is, the defense mustclearly and convincingly establish the defendant'sinsanity, in contrast to the prior requirement that theprosecution clearly and convincingly demonstratethe defendant to have been sane when the prohibitedact was committed.

This shifting of the burden of proof for the insanitydefense, by the way, had been instituted by many states inthe wake of the Hinckley acquittal. The intent of thisreform was to discourage use of the insanity defense, and itproved quite effective in altering litigation practices in theintended direction (Steadman et aI., 1993).

At the present time, most states and the District ofColumbia subscribe to a version of either the ALl or the

more restrictive M'Naghten standard. New York is a spe-cial case. It uses a version of M'Naghten to define insan-ity, with the burden of proof on the defense, but anelaborate procedural code has been enacted to promotefairness in outcomes while ensuring lengthy and restric-tive hospital commitment for defendants judged to bedangerous; this approach appears to have worked well(Steadman et aI., 1993). In some jurisdictions, when aninsanity plea is filed, the case is submitted for pretrialscreening, which includes a psychiatric evaluation, reviewof records, and appraisal of criminal responsibility. Inone study of 190 defendants who entered a plea of notcriminally responsible, the following outcomes wereobtained: 105 were judged to be criminally responsible,charges against 34 were dropped, and 8 defendants wereagreed by both the prosecution and the defense to beinsane and not responsible. A total of 134 withdrew theirinsanity pleas (Janofsky, Dunn, et aI., 1996). The insanitydefense was noted in this study to be somewhat of a "richman's defense" in that such cases involved private attor-neys rather than public defenders.

Silver (1995) found that the successful use of theNGRI defense varied widely among states. In addition, Sil-ver reported that the length of confinement was relatedmore to the judged seriousness of the crime than towhether the person was employing the NGRI defense. Onestudy (Cirinclone, Steadman, & McGreevy, 1995) foundthat an NGRI plea was most likely to be successful if one ormore of the following factors were present:

A diagnosed mental disorder, particularly a majormental disorder

A female defendant

The violent crime was other than murder

There had been prior mental hospitalizations

Three states-Idaho, Montana, and Utah-haveentirely abolished the attribution of insanity as an accept-able defense for wrongdoing-a somewhat draconiansolution that compensates in clarity for what some feel itlacks in compassion. As expected, with the disappearanceof the insanity acquittals in Montana there was a corre-sponding rise in the use of "incompetent to stand trial;' inwhich the charges were actually dismissed, largely negat-ing the desired result (more effective prosecution) ofdoing away with the insanity defense (Callahan, Robbins,et aI., 1995).

How, then, is guilt or innocence determined? Manyauthorities believe that the insanity defense sets the courtsan impossible task-to determine guilt or innocence byreason of insanity on the basis of psychiatric testimony. Ina number of cases, conflicting testimony has resultedbecause both the prosecution and the defense have "their"panel of expert psychiatric witnesses, who are in completedisagreement (Marvit, 1981).

Finally, states have adopted the optional plea/verdictof guilty but mentally ill (GBMI). In these cases, a defen-dant may be sentenced but placed in a treatment facilityrather than in a prison. This two-part judgment serves toprevent the type of situation in which a person commits amurder, is found not guilty by reason of insanity, is turnedover to a mental health facility, is found to be rational andin no further need of treatment by the hospital staff, and isunconditionally released to the community after only aminimal period of confinement. Under the two-part deci-sion, such a person would remain in the custody of the cor-rectional department until the full sentence had beenserved. Marvit (1981) has suggested that this approachmight "realistically balance the interest of the mentally illoffender's rights and the community's need to controlcriminal behavior" (p. 23). However, others have arguedthat the GBMI defense is confusing to jurors and should beeliminated (Melville & Naimark, 2002). Interestingly, inGeorgia, one of the states adopting this option, GBMIdefendants received longer sentences and longer periods ofconfinement than those who pleaded NGRI and lost.Overall, outcomes from use of the GBMI standard, whichis often employed in a plea-bargaining strategy, have beendisappointing (Steadman et aI., 1993).

In ReVIew~ What conditions must be met before an

individual can be involuntarily committed toa mental institution? Describe the legalprocess that follows.

~ What is the insanity (NGRI)defense incriminal cases?

~ What are the implications of the Tarasoffdecision for practicing clinicians?

ORGANIZED EFFORTSFOR MENTAL HEALTHPublic awareness of the magnitude of contemporary men-tal health problems and the interest of government, pro-fessional, and lay organizations have stimulated thedevelopment of programs directed at better understand-ing, more effective treatment, and long-range prevention.Efforts to improve mental health are apparent not only inour society but also in many other countries, and theyinvolve international as well as national and local organi-zations and approaches.

In the United States in the eighteenth and nineteenth cen-turies, dealing with mental disorders was the primaryresponsibility of state and local agencies. During WorldWar II, however, the extent of mental disorders in theUnited States was brought to public attention when a largenumber of young men-two out of every seven recruits-were rejected for military service for psychiatric reasons.This discovery led to a variety of organized measures fortaking care of people with mental illness.

THE FEDERAL GOVERNMENT AND MENTAL HEALTHIn 1946, aware of the need for more research, training, andservices in the field of mental health, Congress passed itsfirst comprehensive mental health bill, the National Men-tal Health Act. In that same year, the National Institute ofMental Health (NIMH) was formed in Washington, DC.The agency was to serve as a central research and trainingcenter and as headquarters for the administration of agrant-in-aid program designed to foster research andtraining elsewhere in the nation and to help state and localcommunities expand and improve their own mentalhealth services. Congress authorized the institute to pro-vide "mental health project grants" for experimental stud-ies, pilot projects, surveys, and general research. Today theNIMH is a separate institute under the National Institutesof Health, within the Department of Health and HumanServices (NIMH, 2001).

The NIMH (1) conducts and supports research on thebiological, psychosocial, and sociocultural aspects of men-tal disorders; (2) supports the training of professional andparaprofessional personnel in the mental health field;(3) helps communities plan, establish, and maintain moreeffective mental health programs; and (4) provides infor-mation on mental health to the public and to the scientificcommunity. Two companion institutes-the NationalInstitute on Alcohol Abuse and Alcoholism (NIAAA) andthe National Institute on Drug Abuse (NIDA)-performcomparable functions in these more specialized fields.

Although the federal government provides leadershipand financial aid, the states and local organizations actu-ally plan and run most NIMH programs. Most state andlocal governments, however, have not been able to fundprograms and facilities because of cuts in federal support.As a result, many programs devoted to mental healthtraining, research, and service have been greatly reduced orabandoned, even as the need for them has increased. Thereis considerable uncertainty about the extent to which men-tal health problems will be included in forthcoming revi-sions of national health care policy and about what formsany such inclusion might take.

PROfESSIONAL ORGANIZATIONS AND MENTALHEALTH A number of national professional organiza-tions exist in the mental health field. These include the

American Psychological Association (APA), the AmericanPsychological Society (APS), the American PsychiatricAssociation (APA), the American Medical Association(AMA), the Association for the Advancement of BehaviorTherapy (AABT), the American Association for Correc-tional and Forensic Psychology (AACFP), and the Ameri-can Association for Social Work.

A key function of professional organizations is theapplication of insights and methods to contemporarysocial problems-for example, in lobbying national andlocal government agencies to provide more services forhomeless people. Professional mental health organizationsare in a unique position to serve as consultants on mentalhealth problems and programs.

Another important function of these organizations isto set and maintain high professional and ethical standardswithin their special areas. This function may include(1) establishing and reviewing training qualifications forprofessional and paraprofessional personnel; (2) settingstandards and procedures for the accreditation of under-graduate and graduate training programs; (3) setting stan-dards for the accreditation of clinics, hospitals, or otherservice operations and carrying out inspections to see thatthe standards are followed; and (4) investigating reportedcases of unethical or unprofessional conduct and takingdisciplinary action when necessary.

THE ROLE OF VOLUNTEER ORGANIZATIONS ANDAGENCIES Although professional mental health person-nel and organizations can give expert technical advice withregard to mental health needs and programs, informed cit-izens are essential in planning and implementing theseprograms. In fact, it is primarily concerned nonprofession-als who have blazed the trails in the mental health field.

Prominent among the many volunteer mental healthagencies is the National Mental Health Association(NMHA). This organization was founded in 1909 by Clif-ford Beers as the National Association for Mental Healthand expanded by the merger of the National Committeefor Mental Hygiene, the National Mental Health Founda-tion, and the Psychiatric Foundation; it was furtherexpanded in 1962 by merging with the National Organiza-tion for Mentally III Children. The NMHA works for theimprovement of services in community clinics and mentalhospitals; it helps recruit, train, and place volunteers forservice in treatment and aftercare programs; and it worksfor enlightened mental health legislation and for the provi-sion of needed facilities and personnel. It also carries onspecial educational programs aimed at fostering positivemental health and helping people understand mental dis-orders. In addition, the National Mental Health Associa-tion has been actively involved in many court decisionsaffecting patient rights (1997). In several cases, the organi-zation has sponsored litigation or served as amicus curiae(friend of the court) in efforts to establish the rights ofmental patients to treatment, to freedom from custodial

confinement, to freedom to live in the community, and toprotection of their confidentiality.

The National Association for Retarded Citizens(NARC) works to reduce the incidence of mental retarda-tion, to seek community and residential treatment centersand services for the retarded, and to carryon a program ofeducation aimed at better public understanding of retardedindividuals and greater support for legislation on theirbehalf. The NARC also fosters scientific research into men-tal retardation, the recruitment and training of volunteerworkers, and programs of community action.

These and other volunteer health organizations suchas Alcoholics Anonymous and the National Alliance for theMentally III (NAMI) need the backing of a wide con-stituency of knowledgeable and involved citizens in orderto succeed.

MENTAL HEALTH RESOURCES IN PRIVATE INDUSTRYPersonal problems-such as marital distress or otherfamily problems, alcohol or drug abuse, financial difficul-ties, and job-related stress-can adversely affect employeemorale and performance. Psychological difficulties amongemployees may result in numerous problems such asabsenteeism, accident proneness, poor productivity, andhigh job turnover. The National Institute for OccupationalSafety and Health (NIOSH) recognizes psychological dis-orders as one of the ten leading work-related health prob-lems (Millar, 1990), and work-related mental health riskfactors may be increasing with changes in the economy, intechnology, and in demographic factors in the workforce(Sauter, Murphy, & Hurrell, 1990). Since passage of theAmericans with Disabilities Act, people with psychiatricproblems cannot be discriminated against in the work-place. Employers are encouraged to alter the workplace, asneeded, to accommodate the needs of persons with mentalillness. Although employers often object that it is too costlyto hire psychiatrically impaired persons, great benefits forsociety can result from integrating into productive jobspeople who have disabilities but also have appropriateskills (Kramer, 1998).

A great deal more research is needed to identify spe-cific mental health risk factors in work situations. Wealready know (e.g., Sauter et al., 1990) that serious unrec-ognized problems may exist in the following areas of jobdesign and conditions of work.

1. Work load and pace. The critical factor hereappears to be the degree of control the worker hasover the pace of work, rather than output demand.Machine-paced assembly work may be particularlyhazardous to mental health.

2. Work schedule. Rotating shifts and night workhave been associated with elevated risk forpsychological difficulties.

3. Role stressors. Role ambiguity (such as uncertaintyabout who has responsibility for what), said to be

common in many work situations, has a negativeimpact on mental and physical health, as does roleconflict (incompatible role demands).

4. Career security factors. Feelings of insecurityrelated to issues such as job future or obsolescence,career development, and encouragement of earlyretirement adversely affect mental and physicalhealth.

5. Interpersonal relations. Poor or unsupportiverelationships among work colleagues significantlyincrease the risk of untoward psychologicalreactions.

6. Job content. Poor mental health has beenassociated with work assignments involvingfragmented, narrow, unvarying tasks that allow forlittle creativity and give the worker little sense ofhaving contributed to the ultimate product.

Many corporations have long recognized the impor-tance of worker mental health and of enhancing mental-health-promoting factors in the workplace, yet only recentlyhave many of them acted on this knowledge. Today manycompanies have expanded their "obligations" to employeesto include numerous psychological services. Employeeassistance programs (EAPs) are means through whichlarger corporations can actively provide mental health ser-vices to employees and their family members. In general,employers have been slower to deal with issues of jobdesign and work environment as additional means of max-imizing worker mental health.

International Efforts forMental HealthMental health is a major issue not only in the United Statesbut also in the rest of the world. Indeed, many of the prob-lems in this country with regard to the treatment of men-tal disorders are greatly magnified in poorer countries andcountries with repressive governments. The severity of theworld mental health problem is reflected in the WorldHealth Organization's estimate that mental disorders affectmore than 200 million people worldwide, partly because ofthe significant world refugee crisis (de Jong, 2002; Watters& Ingleby, 2004). Recognition of this great problem servedto bring about the formation of several international orga-nizations at the end of World War II. Here we will brieflydiscuss the World Health Organization and the WorldFederation for Mental Health.

THE WORLD HEALTH ORGANIZATION The WorldHealth Organization (2001) has always been keenly awareof the close interrelationships among physical, psychoso-cial, and sociocultural factors. Examples include the influ-ence of rapid change and social disruption on bothphysical and mental health; the impossibility of majorprogress toward mental health in societies where a large

proportion of the population suffers from malnutrition,parasites, and disease; and the frequent psychological andcultural barriers to successful programs in family planningand public health (Rutz, 2001).

Formed after World War II as part of the UnitedNations system, WHO's earliest focus was on physicaldiseases; it has helped make dramatic progress towardthe conquest of such ancient scourges as smallpox andmalaria. Over the years, mental health, too, became anincreasing concern among the member countries. WHO'spresent program integrates mental health concerns withthe broad problems of overall health and socioeconomicdevelopment that many member countries face (WorldHealth Organization, 1997).

Another important contribution of WHO has been itsInternational Classification of Diseases (ICD), whichenables clinicians and researchers in different countries touse a uniform set of diagnostic categories. As we saw inChapter 4, the American Psychiatric Association's DSM -IVclassification has been coordinated with the WHO'sICD-10 classification (Sartorius et al., 1993).

THE WORLD FEDERATION FOR MENTAL HEALTH TheWorld Federation for Mental Health was established in1948 as an international congress of nongovernmentalorganizations and individuals concerned with mentalhealth. Its purpose is to promote international cooperationamong governmental and nongovernmental mental healthagencies, and its membership now extends to more than 50countries. The federation has been granted consultativestatus by WHO, and it assists the UN agencies by collectinginformation on mental health conditions all over theworld (World Health Organization, 1997).

The last century witnessed an amazing openness anda lowering of previously impassable barriers betweennations. Along with this increased interchange of ideasand cooperation, we expect to see a broader mental healthcollaboration. It is vital that greater international cooper-ation in the sciences and in health planning continue,along with more sharing of information and views onmental health.

In ReVIew~ What is the role of the National Institute of

Mental Health in providing care for thementally ill?

~ What is the NMHA and how does it contributeto improvement in mental health services?

~ What is the WHO?

CHALLENGES FOR THEFUTUREEven though international cooperation in efforts to under-stand and enhance mental health is encouraging, themedia confront us daily with the stark truth that we have along way to go before our dreams of a better world are real-ized. Many people question whether the United States orany other technologically advanced nation can achievemental health for the majority of its citizens in our time.Racism, poverty, youth violence, terrorism, the uprootingof developing world populations, and other social prob-lems that contribute to mental disorder sometimes seeminsurmountable.

Other events in the rest of the world affect us also,both directly and indirectly. Worldwide economic instabil-ity and shortages and the possibility of the destruction ofour planet's life ecology breeds widespread anxiety aboutthe future. The vast resources we have spent on militaryprograms over the past half-century to protect against per-ceived threats have absorbed funds and energy that other-wise might have been devoted to meeting human andsocial needs here and elsewhere in the world. The limitedresources we are now willing to allocate to mental healthproblems prevent our solving major problems resultingfrom drug and alcohol abuse, homelessness, broken fami-lies, and squalid living conditions.

The Need for PlanningIf mental health problems are going to be reduced or elim-inated, it seems imperative that more effective planning bedone at community, national, and international levels.Many challenges must be met if we are to create a betterworld for ourselves and future generations. Withoutslackening our efforts to meet needs at home, we willprobably find it essential to participate more broadly ininternational measures aimed at reducing group tensionsand promoting mental health and a better world for peo-ple everywhere. At the same time, we can expect that mea-sures we undertake to reduce international conflict andimprove the general condition of humankind will make asignificant contribution to our own nation's socialprogress and mental health. Both kinds of measures willrequire understanding and moral commitment from con-cerned citizens.

Within our own country and the rest of the industri-alized world, progress in prolonging life has brought withit burgeoning problems in the prevalence of disordersassociated with advanced age, particularly in the area ofconditions such as Alzheimer's disease. Judging by thenumbers of people already affected) it is not certain at thistime that we will find the means of eradicating or arresting

this threat before it has overwhelmed us. Planning andpreparation would seem our only rational hope of fore-stalling a potential disaster of unprecedented magnitude;we need to make a beginning.

History provides clear examples of individuals whoseefforts were instrumental in changing the way we thinkabout mental health problems. Recall that Pinel took offthe chains, Dorothea Dix initiated a movement to improvethe conditions of asylums, and Clifford Beers inspired themodern mental health movement with his autobiographi-cal account of his own experience with mental illness. Whowill lead the next revolution in mental health is anyone'sguess. What is clear is that a great deal can be accomplishedby individual effort.

When students become aware of the tremendousscope of the mental health problem both nationally andinternationally and of the woefully inadequate facilities forcoping with it, they often ask, "What can I do?" Thus itseems appropriate to suggest a few of the lines of actionthat interested students can take.

Many opportunities in mental health work are open totrained personnel, both professional and paraprofessional.Social work, clinical psychology, psychiatry, and othermental health occupations are personally fulfilling. Inaddition, many occupations, ranging from law enforce-ment to teaching and the ministry, can and do play keyroles in the mental health and well-being of many people.Training in all these fields usually offers individuals oppor-tunities to work in community clinics and related facilities,to gain experience in understanding the needs and prob-lems of people in distress, and to become familiar withcommunity resources.

Citizens can find many ways to be of direct service ifthey are familiar with national and internationalresources and programs and if they invest the effort nec-essary to learn about their community's special needs andproblems. Whatever their roles in life-student, teacher,police officer, lawyer, homemaker, business executive, ortrade unionist-their interests are directly at stake, foralthough the mental health of a nation may be mani-fested in many ways-in its purposes, courage, moralresponsibility, scientific and cultural achievements, andquality of daily life-its health and resources derive ulti-mately from the individuals within it. In a participatorydemocracy, it is they who plan and implement thenation's goals.

Besides accepting some measure of responsibility forthe mental health of others through the quality of one'sown interpersonal relationships, there are several otherconstructive courses of action open to each citizen. Theseinclude (1) serving as a volunteer in a mental hospital,

community mental health center, or service organization;(2) supporting realistic measures for ensuring comprehen-sive health services for all age groups; and (3) workingtoward improved public education, responsible govern-ment, the alleviation of prejudice, and the establishment ofa more sane and harmonious world.

All of us are concerned with mental health for per-sonal as well as altruistic reasons, for we want to overcomethe nagging problems of contemporary living and find ourshare of happiness in a meaningful and fulfilling life. To doso, we may sometimes need the courage to admit that ourproblems are too much for us. When existence seems futileor the going becomes too difficult, it may help to remindourselves of the following basic facts, which have beenemphasized throughout this text: From time to time, eachof us has serious difficulties in coping with the problems ofliving. During such crises, we may need psychological andrelated assistance. Such difficulties are not a disgrace; theycan happen to anyone if the stress is severe enough. Theearly detection and treatment of maladaptive behavior areof great importance in preventing the development ofmore severe or chronic conditions. Preventive measures-universal, selected, and indicated-are the most effectivelong-range approach to the solution of both individualand group mental health problems.

Statistics show that nearly all of us will at some time inour lives have to deal with severely maladaptive behavioror mental disorder either in ourselves or in someone closeto us. Our interdependence and the loss to us all, individu-ally and collectively, when anyone of us fails to achieve hisor her potential are eloquently expressed in the famouslines ofJohn Donne (1624):

No man is an island, entire of itself; every man is apiece of the continent, a part of the main. If a clod bewashed away by the sea, Europe is the less, as well as ifa promontory were, as well as if a manor of thy friendsor of thine own were: any man's death diminishes me,because I am involved in mankind, and thereforenever send to know for whom the bell tolls; it tollsfor thee.

In ReVIew~ After reading the Unresolved Issues feature,

discuss the controversy over the effects ofmanaged health care on the treatment andprevention of mental illness.

~ Describe several ways in which individualscan contribute to the advancement of mentalhealth.

511 s noted in Chapter 1, in any 12-month periodthe lives of more than 37 million adults inthis country are affected by mental illness ofsome kind (Kessler, Chiu, et aI., 2005). Onlyabout one in five with a disorder receives

mental health treatment (Castro, 1993). It has been estimatedthat psychiatric treatment accounts for about one-quarter ofall hospital stays in America (Kiesler & Sibulkin, 1987). Healthcare costs in general are reportedly rising more rapidly thanany other aspect of the American economy (Resnick & DeLeon,1995). Some businesses have spent as much on health carefor employees as they have earned (O'Connor, 1996). In the1990S health care costs skyrocketed as the number of peoplereceiving services increased over 30 percent per year (Giles,1993). The "gate keeping" function of HMOs has clearlyaffected access to mental health care in the United States inthat business decisions often take precedence over treatmentneed. Treatment, when it is allowed by the HMO, tends to belimited in both duration and quality. As we have seen in thischapter, mental health treatment is valuable for preventing aswell as easing mental disorders. Yet the current crisis in healthcare has meant that mental health treatment is less readilyavailable and that its cost is less often reimbursed.

In response to these needs, health care administratorshave created a diverse array of programs in an attempt to pro-vide services at a cost that society can afford. In managedhealth care, a system of corporations secures services fromhospitals, physicians, and other providers/workers for a des-ignated population (Frank, McDaniel, et aI., 2004). Managedhealth care providers attempt to offer medical care at lowercosts by limiting traditional services, employing stringentreview procedures, and using lower-cost, brief treatmentoptions. These systems operate by marketing health careplans to employers or individuals. For a fixed prepaid fee,employers and individuals subscribe to a health service com-pany or a health maintenance organization (HMO), whichentitles them to the services provided by that health plan.These programs establish a treatment staff through systemsof professionals, referred to as "panels," who are consideredto have efficacy and efficiency in providing a wide range ofservices. Some HMOs-referred to as "open-panel sys-tems" - allow patients some choice of health providers andallow any qualified professional in the community to partici-pate. However, most are closed-panel systems, which limitthe selel';on of available providers. The benefits vary fromplan to plan and usually include limits on the problems cov-ered or on the maximum amount of care provided or servicesavailable. To keep costs low, some HMOs operate accordingto a system of "capitation," a method of payment in which ahealth care provider contracts to deliver all the health careservices required by a population for a fixed cost or flat feeper enrolled member or employee (Sanchez & Turner, 2003).

The HMO thus assumes some risk, but capitation allows for

great profit if the subscriber's fees can be set higher than thecost of health services.

Mental Health Treatment-Who Decides WhatKind and How long?In one common approach to reducing health care costs, themanaged care agency negotiates a reduced price directly withthe health service provider. The provider then bills the healthservice organization for the time spent, and the HMO canobtain "low-bid" services from the health professional(Richardson & Austad, 1994). This approach poses little finan-cial risk to the provider. As might be apparent to the casualobserver of managed care systems, the procedures for deter-mining the amount of money paid to providers have fre-quently been a problem for mental health professionals-psychologists and psychiatrists (Resnick et aI., 1994). TheHMO representative or "gatekeeper" to reimbursement, oftena medical generalist untrained in either psychiatric disordersor psychosocial interventions, controls access to therapy andsometimes the type of treatment to be provided (Resnicket aI., 1994). In some systems of managed care, the gate-keeper might be a business professional who, in the view ofthe health service provider, is blocking adequate treatmentby demanding that the clinician periodically justify treatmentdecisions to someone who has little or no background inmental health. Conflicts frequently develop in such situa-tions, and patients may be deprived of appropriate and nec-essary care (Resnick et aI., 1994).

Managed care programs differ widely in the modes andquality of mental health services provided. Although theirstated intention is to provide the most effective treatmentsavailable, decisions about what treatments to provide areoften based more on business factors than on treatment con-siderations. HMOs that are overly cost-conscious have cometo be viewed by many in the mental health field as simplytending to business and neglecting the patients' needs(Karon, 1995).

TIme-limited TherapyThe mental health services typically covered by HMOs tend tofavor less expensive and less labor-intensive approaches. Asmight be expected, pharmacotherapy is the most frequentmental health treatment provided by HMOs. About 10 percentof the population in the United States receives some pre-scribed psychoactive medication each year (Klerman et aI.,1994), a situation that some research suggests actuallyreduces health care costs. Some research has also shownthat cost-containment measures that are intended to reducedrug costs by restricting access to medications can-andoften do-wind up increasing total health care costs (Horn,2003). Some managed health care systems have advocated

the expanded USeof somatic therapies in an attempt to con-

tain costs. Psychosocial interventions such as individual psy-chotherapy are discouraged or limited to relatively few ses-sions. Long-term psychotherapy has been virtually eliminatedfor all but a small number of wealthy private clients (Lazarus,1996). On the other hand, group psychotherapy is often pro-moted and encouraged because it is often thought of ascost-effective.

Most managed care corporations have adopted themodel of providing focused, brief, intermittent mental healthtreatment (Cummings, 1995) for most problems. Patients whorequire longer treatments or need inpatient hospitalizationare typically not well served in managed care organizations.In fact, long-term mental health treatment is usually discour-aged by managed health care organizations. For example,most managed care groups approve only short inpatientstays (less than 10 days) and four to six sessions of outpa-tient mental health treatment at a time. Few if any of the deci-sions regarding the amount and type of services provided aredirectly guided by empirical criteria. Decisions whether tocover 8 or zo sessions of psychotherapy, for example, arearbitrary and often seem capricious to both practitioner andpatient (Harwood et aI., 1997).

A clear divide has developed between health serviceproviders and managers. Available services are often gov-erned more by financial concerns than by a mental health pro-fessional's judgment. Practitioners, as a result, are expressingdisagreement over the situation. Critics of managed careargue that there is no convincing evidence that current effortsare actually controlling costs (Gabbard, 1994; Harwood et aI.,1997) and that there is no scientific support for the Iimited-benefit options being exercised. Some data suggest thatsome measures that are designed to reduce drug costs by

restricting access to medications can actually wind upincreasing total health care costs (Horn, Z003). Someresearchers have pointed out that the administrative costs formanaged care centers (including high salaries for HMO exec-utives) are exorbitant. Gabbard (1994), for example, esti-mated that about one-fourth of the health care expendituresin the United States go for managed care administration.

The revolution in health care has clearly created contro-versy in the field of psychotherapy. The mental health field isbeing drastically altered by economic considerations.Recently, Sanchez and Turner (zo03) provided an overview ofthe impact of managed care on psychological practice and theprovision of mental health services to clients in need. Theypointed out that the economics of the current health care sys-tem have greatly impacted the practice of behavioral healthcare by limiting treatment to time-limited, symptom-focusedservices. They note that this environment has resulted in dra-matic changes in the way psychological services are deliveredto people in need. The most frequently cited changes includethe remarkable shift of treatment decision-making powerfrom the behavioral health care provider to policymakers. Inaddition, practitioners have experienced a reduction inincome, which has likely impacted quality of care since less-well-trained (non-doctoral-level) therapists have taken onmore responsibility and offer short-term therapeuticapproaches instead of needed long-term therapy. Thesegrowing pains are likely to continue as our society attemptsto come to terms with the cost of health care and the need toensure that it is available. One thing is certain: The nature ofthe mental health professions is changing, and there is agrowing discontent with health maintenance organizations insociety today (Mechanic, Z004).

~ Many mental health professionals are trying not onlyto cure mental health problems but also to preventthem, or at least to reduce their effects.

~ Prevention can be viewed as focusing on three levels:(1) universal interventions, which attempt to reducethe long-term consequences of having had adisorder; (z) selective interventions, which are aimedat reducing the possibility of disorder and fosteringpositive mental health efforts in subpopulations thatare considered at special risk; and (3) indicatedinterventions, which attempt to reduce the impact orduration of a problem that has already occurred.

~ Over the past 40 years, with the advent of many newpsychotropic medications and changing treatmentphilosophies, there has been a major effort todischarge psychiatric patients into the community.

~ There has been a great deal of controversy overdeinstitutionalization and the failure to provideadequate follow-up of these patients in thecommunity.

~ Recent work in the area of aftercare for former mentalpatients has provided clearer guidelines fordischarge and therapeutic follow-up.

~ Being "mentally ill" is not considered sufficientgrounds for involuntary commitment. There must be,

in addition, evidence that the individual either isdangerous to himself or herself or represents adanger to society.

~ It is not an easy matter, even for trained professionals,to determine in advance whether a person isdangerous and likely to harm others. Nevertheless,professionals must sometimes make such judgments.

~ Recent court rulings have found professionals liablewhen patients they were treating caused harm toothers. The Tarasoff decision held that a therapist hasa duty to protect potential victims if his or her patienthas threatened to kill them.

~ The insanity plea for capital crimes is an importantissue in forensic psychology. Many mental health andlegal professionals, journalists, and laypersons havequestioned the present use of the "not guilty byreason of insanity" (NGRI) defense.

~ The original legal precedent, the M'Naghten Rule, heldthat at the time of committing the act, the accusedmust have been laboring under such a defect of reasonas not to know the nature and quality of the act or notto know that what he or she was doing was wrong.

~ More recent broadenings of the insanity plea, as inthe American Law Institute standard, leave open thepossibility of valid NGRI pleas by persons who are notdiagnosed to be psychotic.

~ The successful use of the NGRIdefense by JohnHinckley, attempted assassin of President Reagan,set off a storm of protest. One effective and widelyadopted reform was to shift the burden of proof (ofinsanity) to the defense.

~ Federal agencies such as the National Institute ofMental Health (NIMH), the National Institute on DrugAbuse (NIDA), and the National Institute on AlcoholAbuse and Alcoholism (NIAAA) are devoted topromoting research, training, and service in themental health community.

~ Several professional and mental health organizations,many corporations, and a number ofvolunteerassociations are also active in programs to promotemental health.

~ International organizations such as the World HealthOrganization (WHO) and the World Federation forMental Health have contributed to mental healthprograms worldwide.

deinstitutionalization (P. 650)

forensic psychology (forensicpsychiatry) (p.652)

guilty but mentally ill (GBMI)(p.661)

health maintenance organization(HMO) (P. 666)

indicated interventions (P. 642)

insanity defense (P. 657)

managed health care (P. 666)

milieu therapy (P. 648)

NGRI plea (P. 657)

selective interventions (P. 642)

social-learning programs (P. 649)

Tarasoff decision (P. 656)

universal interventions (Po 642)