91172.pdf

172 7 Court and the Legal System—Civil Forensics

there is no standard test for competency. While competency to accept or refuse

treatment stands as a major legal issue, it seems that a more direct confrontation of

this issue is necessary.

LEAST RESTRICTIVE ALTERNATIVE DOCTRINE

Introduction

One of the most significant developments in mental health law and policy over
the past 20 years concerns what may be regarded as the third substantive criterion
for commitment. The Least Restrictive Alternative (LRA) doctrine requires that
individuals be placed in the least restrictive setting when their condition necessitates
state intervention. In situations involving persons who are considered dangerous to
self or others and are, thus, candidates for involuntary commitment, the restric-
tiveness of the setting must be a consideration. In addition to setting, however, the
doctrine also requires the least restrictive method of treatment. The ultimate goal,
then, is to protect the individual's freedom from "unnecessary and harmful treat-
ment" (Arrigo, 1993, p. 152), while serving the individual's interest in receiving
effective treatment and services.
Given that the restrictiveness of a setting and the type of treatment administered
becomes a concern of the state, several issues arise. First, the concept of restric-
tiveness (like the concepts of mental illness and dangerousness) must be adequately
defined and operationalized. In other words, what settings and treatment plans
constitute less restrictive ones than others? The traditional assumption has been
that hospitalization is the most restrictive setting and that other settings such as
community-based programs become progressively less restrictive. This assumption,
however, has been the subject of much debate. In particular, this debate hinges on
the issue of what is truly in the best interest of the individual. Like many forensic
controversies, this matter becomes a common point of disagreement between psy-
chology and law. This section will explore some of the key issues with regard to
the LRA doctrine.

John is a 42-year-old librarian with a history of mental illness. Though prone to bouts

of mental deterioration, his functioning has historically returned to "normal" within a

few weeks. John is currently single with no children and no living family members.

During this particular week, John's functioning has been markedly poor. He is unable

to perform his work-related duties and is clearly unable to care for himself. While he

represents no danger to himself or others, he is unquestionably in need of psychiatric

care. John's coworkers concern for his well-being prompted him to seek help. After

examination by several mental health professionals it was decided that John be required

to participate in some treatment program. Thus, John is a candidate for commitment.

The question for John is such: what is the best placement and treatment for John given

that he represents no danger to himself or others? Is involuntary hospitalization really the

best alternative given John's individual needs?