VRAs, Civil Competencies, Forensic Tx Flashcards
Barefoot v Estelle
1983
Psychiatric opinions about dangerousness were valid and acceptable in court
Coble v Texas (2010) - Must provide evidence that such testimony meets Daubert standards
Kansas v Hendricks
1997
Courts can impose a civil means of lengthening commitment post-sentence for certain populations (SVPs), noting that risk assessment must demonstrate uncontrollable bxs and the person be at high risk
(Solidified appropriateness of risk assessment in court, some states began requiring the use of risk assessment measures in these cases)
History of risk assessment
Monahan 1981 - psychologists and psychiatrists are accurate no more than 33% of the time
Then came the MacArthur Study, other studies by Monahan reevaluated, and while were still not great at risk prediction, we have many more clinical indicators with which to go off
Actuarial Risk Assessment Measures
VRAG - 600 men from a max security hospital with “serious offenses,” regression models revealed 12 variables for inclusion
HCR-20 - contains 20 items addressing historical, clinical, and risk management variables; scores above the media on can indicate 6-13xs more likely to be violent
MacArthur Violence Risk Assessment Study
In general
Large group of inpatients from acute civil inpatient facilities
18-40yo, multiple ethnicities, male and female
Looked at demographic variables, historical variables (work hx, hx of violence, family hx), contextual variables (social support, stress, presence of weapons), and clinical variables (sxs, type of disorder, substance abuse, level of functioning)
Some variables from the MacArthur Study
Sex (men), prior violence, childhood experience of violence (physical abuse only), dx (co-occurring substance disorder increased risk), psychopathy (not predictive!), delusions (not associated), hallucinations (commands to commit violent acts specifically), violent thoughts, anger
Ideal approach to violence risk assessment
Using a combination approach…over any single actuarial assessment
When can you allow clinical judgement into actuarial risk assessment
When there is questionable validity generalization - when your person falls outside the norm group (white men)
Rare risk or protective factors - broken leg countervailings
Four steps to the VRA process
Identifying empirically valid risk factors
Determine the method for scoring the risk factors
Establishing a procedure for combining the scores
Producing an estimate of violence risk
Pure clinical judgement uses none of these, VRA based on a list of risk factors uses one, SPJ uses two, VRAG has all four
Communicating risk assessment
Use multiple methods
Utilize probabilistic descriptors (%) for common events
Utilize categorical descriptors (low, med, high) for rarer events
Tarasoff v Board of Regents
1976
Therapists DO have a duty to protect
Kansas v Crane
2002
Dangerous individuals needn’t be COMPLETELY unable to control their behavior in order to be committed by the state
(SVP case)
Sexual Offender Risk Assessment Tools
Static-99-R
10 items, AUC .69-.79, doesn’t include all factors relevant
SVR-20
SPJ measure, 20 factors, AUC .56-.83, less research than the STATIC
What is guardianship
A legal mechanism by which the state delegates authority over an individuals person or estate to another party
Guardian - health decisions
Conservator - finances
Guardians can be oversee everything (plenary) or limited to a certain need
What is a commonly used, less restrictive alternative to guardianship?
An advanced directive
Created to avoid the stigma of being a ward
Guardianship hearings
Less rigorous than civil commitment Most last 15 minutes or less Proposed ward didn’t attend 2/3 of them Reports lacked detail Expert was present at 8% of them
States set forth ambiguous benchmarks for what is required (“mental illness”)
In re Boyer
Guardianship
Utah statute was too vague and state Supreme Court pressed for an inability-to-care-for-self standard (grave disability)
Many states take a slightly better approach, looking at functional impairment
Evidentiary standard for guardianship
Some states require considerable evidence of incompetence, others just ask for proof that the person made an incompetent decision (like foolishly spending a lot of money)
Many states don’t require guardianship evaluations prior to a court proceeding, but they can be granted if demanded by the petitioner
Things to consider with guardianship evaluations
Whether incapacity is due to deficits in hearing, sight, processing speed, etc.
Effect the environment may have on perceived incapacities (atrophy in a skill set due to environment discouraging to do so)
Direct Assessment of Functional Status
Guardianship, highly studied instrument
Contains items that assess a variety of functional domains, requires the individual to perform sets of activities that the evaluator assigns points to
Assessment Capacity for Everyday Decision Making
Assesses persons capacity to make a decision with regard to solving their own functional problems
Includes semi structured interview, competency rubric developed by Grisso and Appelbaum
Advanced directive
Instructions from a competent individual, directing or authorizing certain actions if the person becomes unable to make their own decisions
Intended to protect autonomy by delegating wishes to someone else
Durable Power of Attorney
Used to cover nonterminal situations as well as directions concerning property
Competence to make treatment decisions
Requirements of informed consent
Promote autonomy
Encourage rational decision making
Protect safety/welfare of patients or research subjects
Components of a valid informed consent
Appropriate disclosure - what a patient would need to know in order to make an informed decision
A competent patient - presumed unless person has mental disability or is a minor (expression of preference, understanding, appreciation, reasonable decision, reasonable outcome)
Voluntary consent - legal concept the law has not defined well…
Constitutional protections behind right to refuse psychoactive medication
Right to freedom of speech/thought Freedom from cruel and unusual punishment Equal protections (should be able to refuse like persons without MI) Right to privacy and bodily integrity
Competency to make treatment decisions
Determine what they’ve been told so far about the tx (teach and educate as needed)
Why they think the tx is necessary
Risk and benefits of tx
Ability to reason through their own case and apply it
What are their reasons for refusing or consenting
MacCAT-T
Competency to make treatment decisions
20 minutes to administer
Semi structured interview
Results in highly reliable clinical judgements
Capacity to Consent to Treatment Instrument
Hypothetical clinical vignettes with treatments and alternatives, discuss and reason through pros and cons of each
Developed specifically for Alzheimer’s patients but can be used with other populations as well
Instruments for competency to make treatment decisions
MacCAT-T
CCTI
Three types of psychological advanced directives
Patient expresses their treatment preferences
Designates a proxy decisionmaker
Hybrid
(Competency assessment tool for psychiatric advance directives CAT-PAD)
Testsmentary capacity
Competence to execute a will
Must be of sound mind, know they’re making a will, know objects in their bounty and extent of their property, know manner in which the wills distribute their property
Can be current, retrospective eval after death, or looking at undue influence
Differences between criminal and civil commitment
Police power v parens patriae
Criminal conduct that has occurred v future harm to self
Beyond reasonable doubt v clear and convincing
Improvements to civil commitment in the 1970s
Types of lawsuits
Challenges to procedural criteria
Suits concerning institutional conditions (right to tx, least restrictive)
Claims of how tx was administered (right to refuse tx)
General requirements for civil commitment
Has a mental disorder
Dangerous to self or others as a result of the mental disorder
Commitment hearing -> Tx must occur in least restrictive environment
Civil commitment
Need for treatment
Built into most state statues
Looks like language discussing risk of deteriorating without tx
Kendra’s Law
Proposed by NAMI, enacted by NY state
Forces people to comply with outpatient treatment (but does not require forced meds)
Four exceptions to informed consent
Emergencies
If it is waived by the patient
If the informed consent process would cause harm to the patient
When the patient is incompetent
Two stages of inpatient commitment
Emergency admission - like a 72hr hold, no court involvement
Long term commitment - requires judicial approval and an adversarial proceeding, can request jury trial, right to have a judge make the ultimate decision
Commitment of special populations
Parham - child’s commitment only requires a physical determine there is a need for tx (leads to troubling kids getting tx without mental illness)
Vitek - convicted persons are entitled to a hearing before seeing if they should be transferred to a psychiatric facility
Civil commit standard for those with ID
Generally
As a result of ID, the person is likely to injure others or lacks the basic self care or survival skills necessary
Canterbury v Spence
1972
A physician can be liable for malpractice if they fail to disclose rare but severe risks inherent in a medical procedure
Foucha v Louisiana
1992
An insanity acquittee must be both mentally ill and dangerous for a state to justify continued hospitalization
Jones v US
1983
NGRI acquittees can be subject to involuntary and indefinite commitment
Lake v Cameron
1966
A civilly committed patient cannot be involuntarily held in a hospital if there are safer and less restrictive treatment alternatives available
Lessard v Schmidt
1972
Those facing civil commitment should be afforded the same protections as those facing criminal commitment
O’Connor v Donaldson
1975
Mentally ill persons cannot be involuntarily hospitalized if they are not dangerous
Addington v Texas
1979
Clear and convincing is the appropriate burden of proof for civil commitment
Parham v JR
1979
Adversarial hearings are not required for the commitment of a juvenile whose parents or guardian requested the commitment
Rennie v Klein
1980s
Civilly committed persons do not need to have a court order for forced meds
But they have the right to refuse, physician must approach from a “professional judgement” standard
Zinermon v Burch
1990
Incompetent individuals cannot consent to voluntary hospitalization
Washington v Harper
1990
Judicial hearings are not required to satisfy due process for prisoners found to be dangerous and refusing psychiatric medication
Wyatt v Stickney
1972
Individuals committed for MI/MR are entitled to “minimally adequate” standards for psychiatric treatment
Types of Evaluation Systems
Institution based inpatient - eval and tx in the hospital
Institution based outpatient - eval inpt and tx in the hospital
Community based outpatient - evals and tx provided by local agencies
Community based private practice model - no agency or state hospital involvement, individual practitioners are appointed by the court
Mixed - capitalizing in available community resources and supplementing when needed
Forensic treatment systems best suited for large populations
Decentralized systems with a few locations throughout the state
