[Self determination of patients in social psychiatric practice. A medical ethics model and its practical application]. / Die Selbstbestimmung von Patientinnen und Patienten in der sozialpsychiatrischen Praxis. Ein medizinethisches Modell und seine praktische Umsetzung.

To protect patients' autonomy, valid informed consent must be given prior to medical treatment. This includes disclosure of information, understanding, ability to decide freely, and competence/capacity of the patient. However, a psychiatric disorder may disturb the ability to make a choice of their own. These patients have lost their competence to give valid informed consent. In everyday practice of social psychiatry, it is of particular interest to have objective and valid criteria to identify the incompetent patient. These problems are discussed in a case report, and four criteria (understanding, reasoning, decision making and appreciation of the disorder) are presented to diagnose the patients' competence.

Criminality of the mentally ill in sheltered care: are they more dangerous?

The sample of mental patients in sheltered care has a lower arrest rate than the general population in California in all categories of crimes, except for violent crimes. For violent crimes, the sheltered-care population is likely to be arrested at 1.33 times the rate of the state population, even when the heterogeneity of aggravated assault was taken into consideration. This indicates empirically that the mentally ill in sheltered care are more dangerous than the general population. For prediction of criminality, four factors are found to be significant predictors of resident criminality after 1973: (a) prior crime history, (b) age, (c) use of alcohol and drugs, and (d) sex (male). Among these factors, prior crime history is the single most powerful predictor of resident criminal activity. This is another confirmation of most of the previous research findings. Although there have been controversies over the issue of the dangerousness of the mentally ill, the results of this study, overall, support the most recent findings of studies in which the mentally ill population pose greater threats to the community than the general population. Now it is time to consider more specific and practical measures to monitor and carefully follow up the discharged population, especially those with prior crime history, and prevent further violent crimes. This will in turn help to promote the reintegration of the mentally ill in the community.

Regulating professional services in ICFs/MR: remembering the past and looking to the future.

Generally, our society regulates from a standpoint of failure in the system. When the field of mental retardation could not adequately monitor its own professional practices, litigation and legislation brought the onset of government intervention. Historically, consensus building has been the method by which standards emerge and then become adopted into regulation. Yet at best, this practice results in "opinions" as to how quality should be defined. The Health Care Financing Administration's experience in regulating and enforcing has resulted in an emphasis on the outcomes of services received by individuals. Though difficult, it challenges professionals to begin defining accountable measures of "quality" over time.

Regulation and consultation in community care facilities.

Residential community care facilities for deinstitutionalized patients are severely criticized for providing poor-quality care. Yet deinstitutionalization occurred without adequate planning or funding, and facility administrators were left on their own with virtually no regulation and no involvement with the mental health profession. Mental health professionals must focus on improving their understanding of the problems experienced by the community care industry, build alliances with facility administrators, and collaboratively design regulatory and consultative interventions that will help administrators reintegrate the mentally ill into the community. The author uses regulatory and consultative approaches implemented in California and Virginia as case examples.