742 CHAPTER 16
SUMMING UP
Summary of Ethical Issues
Each type of mental health professional works
under his or her own discipline’s ethical code;
all disciplines include in their ethical code the
principle of confidentiality, which applies to
information that patients share with mental
health professionals. Although the clinician is
bound by confi dentiality, patients in couples
therapy, family therapy, and group therapy are
not. When a patient is a minor, the clinician
may inform the parents about what the child
has said; however, most clinicians discuss the
limits of confi dentiality with a child who is old
enough to understand.
Because of HIPAA, the limits on confi den-
tiality have been redefi ned. Now limited infor-
mation about a patient may be shared with
the patient’s other health providers in order
to facilitate treatment. Although laws protect
confi dentiality, confi dentiality may be violated
against the patient’s wishes when a clinician
has reasonable cause to (1) suspect abuse of
children, the elderly, or the disabled or (2) be-
lieve that a patient is likely to do significant
harm to himself or herself (including suicide
attempts) or a specifi ed other person.
The legal counterpart to the ethical
principle of confidentiality is privileged
communication—the protection of confi den-
tial information from disclosure during legal
proceedings; however, in some circumstances,
other people can decide whether the informa-
tion about a patient should be disclosed.
Patients who have impaired cognitive
processes because of a psychological disor-
der (such as schizophrenia) may be able to
provide informed consent to participate in
research if they can understand what they are
consenting to and can reason about it.Thinking like a clinician
Rina is taking medication and seeing a thera-
pist for depression. During one therapy ses-
sion, she remarks, “Sometimes I think my
family would be better off if I were dead.”
Based on what you have read, should Rina’s
therapist violate confidentiality and take
steps to prevent Rina from hurting herself?
Why or why not?
What if, instead, Rina had said about
her multiply handicapped brother, “Some-
times I think my family would be better off if
he were dead”? Would your view of whether
Rina’s therapist should violate confidential-
ity change—why or why not? What would
Rina need to do or say to provide a clear in-
dication that the therapist should violate
confi dentiality?Summary of Criminal
Actions and Insanity
Various tests have been used to determine
whether a defendant is insane. The fi rst was
the M’Naghten test in 1843, followed by the ir-
resistible impulse test. After almost 70 years
came the Durham test. Many states presently
use the American Legal Institute (ALI) test,
which requires either impaired knowledge
that the behavior was wrong (cognition) or im-
paired capacity to resist the impulse to act il-
legally (volition). The Insanity Defense Reform
Acts of the 1980s did away with the volition el-
ement to determine insanity in federal courts.
Two issues are still to be clarifi ed by the
courts: (1) whether someone who is legally
insane must have known that the act was
“wrong” versus “illegal,” and (2) whether
insanity depends on knowing in the abstractthat an act is wrong versus knowing that the
specifi c behavior is wrong in the particular cir-
cumstance. To assess insanity, a jury may rely
on testimony about the defendant’s mental
state during the time leading up to the crime,
the defendant’s history of mental illness prior
to the crime, testimony or reports from expert
witnesses about the defendant’s mental state
or mental illness.
Mental health clinicians may assess a
defendant’s sanity through interviews with
the person, psychological tests and question-
naires, and interviews with family members
and friends. However, such measures may be
affected by the defendant’s experiences in jail,
medications he or she may be taking, the deci-
sion to plead not guilty by reason of insanity
(NGBI), reactions to the crime, coaching from
the defendant’s lawyer or other inmates, and
the way the defendant responds to various
assessment methods. But none of this infor-
mation necessarily indicates the defendant’s
mental state at the time of the crime. Some
states offer alternatives to the insanity de-
fense, including those of diminished capacity
and guilty but mentally ill. Research indicates
that acquittal on the basis of the insanity de-
fense is extremely rare, particularly when the
decision is made by a jury rather than a judge.
Competency to stand trial addresses the
defendant’s mental state before the trial and
whether the defendant is competent to partic-
ipate in his or her own defense; someone who
is not competent to stand trial would also be
deemed not competent to plead guilty and not
competent to waive the right to an attorney.Thinking like a clinician
Jon has been arrested for disturbing the peace
and destroying private property; at 2 a.m. lastjurors said that his apparent deliberateness and preparation, as well as the fact that he
caught himself before falling in front of the train, helped convince them that he was
not psychotic, that he knew what he was doing was wrong.
(Barnes, 2000a)
After his trial, Goldstein was sent to prison, where he was evaluated to determine
whether he needed to be admitted to a psychiatric hospital to become stable. If
so, once stable, he would be returned to prison. In such cases, hospitalizations are
brief, only long enough to get the defendant well enough to return to prison. In
2006, 8 years after the murder, Goldstein’s conviction was overturned because of a
technical misstep during the second trial. In a third trial, Goldstein’s lawyers entered
a plea of guilty, with the understanding that he would serve 23 years in prison, fol-
lowed by 5 years of psychiatric oversight and supervision after his release.