Law and Disorders: Studies Explore Legally Sensitive Judgments in Treating Mental Illness
Bower, Bruce, Science News
Mental health clinicians often make decisions that affect the personal freedom of people with mental disorders and, at times, the collective safety of everyone. Although state and federal laws set the ground rules for voluntary and forced admissions to psychiatric hospitals, clinicians wrestle with ambiguities that a judge's gavel cannot pound into submission.
Consider the following situations:
* A psychiatrist must size up whether a man diagnosed with schizophrenia, who is tormented by voices that only he can hear and suspicious of others' intentions, can discern the risks and benefits of a powerful antipsychotic medication well enough to reject the treatment if he so wishes.
* A psychologist who believes that a depressed woman needs immediate hospitalization to prevent her from committing suicide must either call her to discuss treatment options or threaten her with forcible admission to the hospital if she does not do it herself by the end of the day.
* Police take a man to a psychiatric emergency room after he has screamed at and threatened his wife for several hours from the sidewalk in front of their apartment. The man, identified as intoxicated by a breath analysis, tells physicians of his fury at his wife's many alleged infidelities. His medical records reveal a history of alcoholism. A psychiatrist and a psychiatric nurse must estimate whether the man poses enough of a physical threat to himself or others to be held in the hospital against his will.
Scientific research offers precious little guidance to harried (and hurried) clinicians faced with these situations. That's about to change, however. A landmark 8-year research project, scheduled to conclude in 1996, promises to make significant inroads into understanding the decision-making competence of people with mental disorders, the ways in which they get coerced into treatment, and their potential for violence.
Preliminary findings of this effort were presented in October at the American Academy of Psychiatry and the Law in Maui, Hawaii. The three-pronged investigation is coordinated by 12 researchers and will receive about $12 million from the MacArthur Foundation Research Network on Mental Health and Law, as well as smaller amounts from other sources.
"We're addressing what we see as the central issues in mental health law," asserts John Monahan, a psychologist at the University of Virginia in Charlottesville and director of the network. "Some of our main findings are at variance with what many clinicians have assumed and previous studies have suggested."
Initial results of the competence study, directed by psychiatrist Paul S. Appelbaum and psychologist Thomas Grisso, both at the University of Massachusetts Medical Center in Worcester, bear out this point. Some clinicians and policy makers argue that serious mental disorders routinely render people legally incompetent to make decisions about psychiatric treatment; conversely, patient advocates assert that these conditions usually leave unscathed the ability to reach sensible treatment decisions.
Neither camp can take comfort in the new findings, say Appelbaum and Grisso. Mental illness often coexists with competent decision making, but many hospitalized patients -- up to one-half of those suffering from schizophreniz and one-quarter of those with major depression -- show seriously impaired judgment, they assert.
Systematic screening of patients for signs of legal competence in decision making rarely takes place in psychiatric hospitals, Appelbaum says. He and Grisso are now testing a brief, standardized competence interview, based on their findings, that they hope clinicians will find useful.
The Massachusetts researchers' study of 498 people in three states included people hospitalized for schizophrenia or major depression, people hospitalized with physical symptoms related to heart disease, and healthy people living in nearby communities. …