Legal Representation is Associated with Psychiatric Readmissions

• Author: Arieh Bauer - Razek Khawaled - Paula Rosca - Alexander M. Ponizovsky
• Position: Forensic Psychiatry Unit, Mental Health Services, Ministry of Health, Jerusalem, Israel - The Department for Treatment of Substance Dependence, Ministry of Health, Jerusalem, Israel; cResearch Unit, Mental Health Services, Ministry of Health, Jerusalem, Israel
• Pages: 6-10

6 The Open Law Journal, 2008, 1, 6-10

1874-950X/08 2008 Bentham Open

Open Access

Legal Representation is Associated with Psychiatric Readmissions

Arieh Bauer,a Razek Khawaled,a Paula Rosca,a,b and Alexander M. Ponizovskyc,*

aForensic Psychiatry Unit, Mental Health Services, Ministry of Health, Jerusalem, Israel; bThe Department for Treat-

ment of Substance Dependence, Ministry of Health, Jerusalem, Israel; cResearch Unit, Mental Health Services, Ministry

of Health, Jerusalem, Israel

Abstract: The legal representation at District Psychiatric Boards hearings of psychiatric inpatients committed under a

Compulsory Admission Order is a very important but insufficiently studied issue. This study aimed 1) to review the prac-

tice of legal representation in the western world and Israel, and 2) to test the hypothesis that the legal representation of

compulsorily committed psychiatric patients at their discharge hearings is associated with their subsequent readmission. A

random sample of 153 compulsorily committed patients discharged in 2003 was drawn from Israel’s National Psychiatric

Case Register and their psychiatric readmission over the next two years was reviewed. The 109 patients who were dis-

charged with legal representation (the index group) were compared with the 44 patients who were discharged without le-

gal representation (the control group). Although the groups were comparable on all sociodemographic and background

clinical characteristics the patients from the index group had significantly more readmissions and inpatient days over the

follow-up period than the control group. The results suggest that the involvement of lawyers in the discharge process is

associated with more readmissions and more inpatient time. The possible reasons for this and its implications are dis-

cussed.

Keywords: Lawyer, legal representation, psychiatric inpatient, readmission, inpatient days.

INTRODUC TION

In the last three decades research on frequent psychiatric

readmissions has reported the possible influence of a number

of patient-related and service-related factors (Riecher-

Rossler & Rossler, 1993; Salize & Dressing, 2004). Among

the patient-related variables, male gender (Hodgin, 1992;

Lidz et al., 1993; Eronen et al., 1996), a diagnosis of schizo-

phrenia (Riecher et al., 1991; Cuffel et al., 2002), a history

of admissions (Bernardo & Forchuk, 2001) and the first ad-

mission being compulsory (Munk-Jorgensen et al.,1991;

Fennig et al. 1999; Heilbrun et al., 1999; Feigon & Hays,

2003; Bauer et al., 2007) are the main factors associated with

readmission. Among the service-related factors predicting

readmission are a short hospital stay (Colenda & Hamer,

1989; Figueroa et al., 2004) and inadequate community serv-

ices (Klinkenberg & Calsyn, 1996). One important service-

related factor, however  legal representation at District

Psychiatric Board (DPB) hearings for psychiatric inpatients

committed under a Compulsory Admission Order  has

been insufficiently studied (O’Brien et al., 1995; Singh,

1996; South Australia Mental health Act, 1993; Myers,

1997), even though legal representation exerts a considerable

influence on DPB rulings.

The Legal Representation of Mental Patients in Civil

Commitment Proceedings in Western Countries

Many bodies of mental health legislation override liberty

by allowing the compulsory commitment and outpatient treat-

*Address correspondence to this author at the Mental Health Services, Min-

istry of Health, 2 Ben Tabai St., 93591 Jerusalem, Israel; Tel: 972 2

5657797; Fax: 972 2 5657798;

E-mail: alexande r.ponizovsky@moh.health.gov.il

ment of severely psychotic patients who present a danger to

themselves or others (South Australia Mental health Act,

1993). A recent widespread and much-debated innovation is

legal representation for compulsorily committed patients. In

most countries the representative is a lawyer, but in Austria,

for instance, the representative may also be a social worker

or psychologist. The right to counsel is in many respects the

key to all other safeguards in civil commitment proceedings.

Attorneys help mental patients facing compulsory commit-

ment understand their rights, provide legal advice in exercis-

ing those rights and guide their clients through the legal

thicket. Even patients in the most acute states, who invaria-

bly lack insight into their need for hospitalization and treat-

ment, request their lawyer to get them discharged. Some

lawyers then become overzealous in fighting for their pa-

tients’ discharge, sometimes prematurely, so that the same

patient is readmitted some days later because of exac erbation

of their mental state (Singh, 1996). These patient representa-

tives, usually lawyers, are perhaps driven by the need to

‘sustain their credibility’ before the Board, although counsel

should not regard a Board ruling as reflecting on their pro-

fessional competence (Myers, 1997). A common claim

against legal representation at Board hearings is that while it

does not significantly increase the patient’s chance of being

successfully discharged, it does significantly lengthen the

hearings (O’Brien, 1995).

In the U.S.A, the key court ruling on right to legal repre-

sentation is Gideon v. Wainwright (Gideon, 1963). This rul-

ing  based on the principle of due process  confirmed

the statutory right to get free legal representation to those

facing incarceration for criminal charges who cannot pay for

their own defense. No less than criminal defendants facing

jail or prison for criminal behavior, people suffering from