Although seldom examined fulb in this context, changes in mntal health law - such as the newer standards f o r civil commitment, the right to treatment, and the doctrine of the least restrictive environment - haue accelerated the pace of deinstitutionalization.

The Influence of Law on Deinst it u t io na 1 iza t io n

Stephen Rachlin

The move to deinstitutionalize the psychiatrically ill began before major changes in mental health law were enacted and has continued pari passu with these more recent developments. It may safely be presumed that the influence of courts and legislatures has had an effect, albeit largely inferential, on the de- clining population of state hospitals. Lawyers have been a powerful force in our field over the past decade or two, pushing for reform on a variety of fronts. This chapter will survey three such areas of activism: the changing criteria for civil commitment, the right to treatment, and the concept of the least restric- tive alternative. Today’s therapeutic practices are, as a result of these man- dates, profoundly different from those of the past. Patients are certainly less frequently subjected to prolonged and involuntary hospitalization. Whether they are also faring better than they did before these new policies continues, however, to be widely debated.

Changing Criteria for Civil Commitment

Changes in the law come about either by legislatures’ creating statutes or by judicial interpretation as the result of litigation, the latter being known as case law. In the mental health field, as Rosenzweig (1980) so aptly puts it, re-

L. Bwhrach (Ed.). New Diredionrjor Mcnlal Hcalrh S&m; DIinrfilufionolirotion, no. 17 San Francism: Josrey-Bass. March 1983. 41

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forming legislation has usually been enacted under the gun of litigation. Much of what has transpired in both arenas has gone forth under the due process clause of the Fourteenth Amendment to the U.S. Constitution, which holds that a state cannot deprive a citizen of “life, liberty, or property without due process of law.”

In the 1972 case of Humphrty v. Cady, involving commitment in lieu of sentence following conviction as a sex offender, the United States Supreme Court stated that involuntary hospitalization is a “massive curtailment of lib- erty.” Later that same year, inJackson v. Indiana, where the situation was that of a mentally retarded deaf-mute hospitalized as incompetent to stand trial, the Court held that, as a minimum, due process requires that the nature and duration of the commitment be related to its purpose. Further, the decision expressed surprise that limitations on such state power were not more fre- quently litigated.

Due process is not a fixed concept; rather, it involves a balance be- tween what is to be lost and the fairness with which the government goes about taking it away. Procedural due process refers specifically to the rules under which the deprivation is made and may include such things as notice, a hear- ing, right to counsel, and trial by jury. On the other hand, substantive due process pertains to the criteria and standards under which the decision is to be made.

Standards. An alteration of the principle under which involuntary hos- pitalization would be permitted typifies a substantive modification. Brooks (1974, p. 605) states succinctly: “Coercive civil commitment of the mentally ill in mental hospitals is justified on two bases, which are frequently commin- gled. The first is that it benefits the committed person; this brings into play the parens patrim function of the state. The second is that i t benefits society; this brings into play the police power of the state.” Someone may be subjected to hospitalization under parens patrim, which involves the obligation of the state to care for those of its citizens who are unable to care for themselves, when men- tal illness renders him unable to exercise the judgment to seek help. Cornmit- ment under police power is designed to protect the public from the presumed danger arising from having the mentally ill in its midst. Therefore, an essen- tial ingredient is the accurate prediction or reasonable presumption of danger- ousness.

Civil libertarians usually opt for the dangerousness standard, while medical model proponents generally support the principle of parens patrzae. Al- though it is true that disputes have raged on many levels with reference to which of these two outlooks should prevail, in practice there is significant over- lap. Pure police power commitment would require overt evidence of danger to others as a result of mental illness. Suicidal behavior as a reason for psychiatric hospitalization combines elements of police power and parens patriae, as does

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the concept of grave disability, wherein the individual, as a result of his mental illness, is unable to provide for his basic needs, such as food, clothing, and shelter. A diagnosis of mental illness combined with the need for care and treatment in a hospital because of such a condition is the most conservative parens patriae doctrine.

The recent legal trend toward a requirement of dangerousness as the basis for civil commitment has been quite strong, and may well be a tactic to abolish involuntary hospitalization (Chodoff, 1976). It certainly has been asso- ciated with an increase in community placement of the mentally ill (Treffert, 1975). Before assigning responsibility for this entirely to the legal profession, however, one must acknowledge that not all lawyers with expertise in the men- tal health field are supporters of the dangerousness standard. Slovenko (1973) considers the primary purpose of commitment to be the provision of assistance to the sick person, not to control behavior or protect the safety of others. “Un- workability” is what Rosenzweig (1980) labels the cardinal defect of the dan- gerousness standard, while Brooks (1979) discusses some of the problems in its applicability and even its definition.

My own bias in favor of parens patriae as the criterion for civil commit- ment is stated elsewhere (Rachlin, 1979). Briefly, I see the judgmental impair- ment that can result from serious mental illness as the key element. As Peszke (1975) puts it, the individual has lost the executive and rational functions of the ego. To those who espouse the primacy of physical freedom, I respond that the liberty to be psychotic is not freedom in any responsible sense of the word (Rachlin, 1974).

The patients who would benefit from parens patrim commitments are those who are so severely mentally disabled as to be incompetent to make deci- sions about their treatment. Stone (1975) formulates his view of the essential ingredients ofparens patriae in his “thank you” theory of civil commitment. Five steps are involved. Reliable diagnosis of a severe mental illness is the first, followed by consideration of whether the immediate prognosis involves major distress, and by whether treatment is available. The fourth step is to determine whether the illness impairs the person’s ability to accept treatment and, finally, consideration is given to whether a reasonable man might reject such treat- ment.

Sadoff (1978), while seeing dangerousness as a millstone around the psychiatrist’s neck, suggests a quadrilateral basis for commitment. His first three points are virtually the same as steps one, three, and four of Stone’s, but he then adds that the proposed patient must be likely to cause imminent seri- ous physical or emotional harm to himself or others, as evidenced by recent behavior. In questioning whether a caring society can ignore the health needs of those demonstrably incapable of meeting these requirements for them- selves, Roth (1979) offers another modification to Stone’s “thank you” theory

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by recommending that no parens patriae hospitalization be permitted unless there has been a specific adjudication of competency to consent or to refuse treatment at a commitment hearing. This position is also supported by Tanay (1980). In Utah, as Lebegue and Clark report (1981), the law now requires that a judicial determination of incompetence to refuse treatment must be made prior to hospitalization, although these authors comment that this might actually be in furtherance of the state’s police power interest.

Pawns patriae as a substantive rationale for civil commitment has, over the years, been circumscribed and/or restricted (Roth, 1980). There has also been much attention paid to the requirements for procedural due process in involuntary hospitalization proceedings, thoroughly summarized by Brooks (1979) in volume 4 of this series. (Of course, as both of these authors remind us, judges may also have a paternalistic orientation in their decision-making pro- cesses.) The imposition of procedures similar to those of the criminal justice system on civil commitment hearings is sharply criticized by Stone (1977), a psychiatrist, who notes that good law might be bad medicine, and by Slo- venko (1977), a law professor, who views such a shift as detrimental to pa- tients.

Legislation. The many changes in state laws that have taken place dur- ing the 1970s with respect to extended, rather than emergency, involuntary hospitalization have been reported in tabular form (“Practice Manual, . . , 1979; Schwitzgebel, 1981). Schwitzgebel (1981, pp. 50-54) also provides a useful narrative summary of his survey: All jurisdictions require mental ill- ness. Twenty specify dangerousness, although the statutory langauge varies considerably. The likelihood of serious harm, from a definitional perspective not consistently different from dangerousness, is part of the law in twenty- eight jurisdictions. A provision for the gravely disabled is to be found in thirty- one jurisdictions, while twenty-three make reference to the need for care and treatment. Most states specify more than one standard; dangerousness or like- lihood of serious harm combined with grave disability or the need for treat- ment are the most frequent. The need for treatment is seldom added to new statutes and, in fact, is more usually dropped.

A report on the process of state law change in Arizona, with particular reference to the thinking and discussion that has transpired, is provided by Beigel, Hegland, and Wexler (1978). Rubenstein, Zonana, and Crane (1977) furnish a similar account for Connecticut, and add a practice manual. This procedure has become typical in state medical journal articles designed to fa- miliarize physicians with the provisions of modified commitment statutes. Many such state laws have resulted in decreasing rates of hospitalization and in the turning away of some acutely ill patients (Shore, 1978). In some cases, judges have found the burden of proof too demanding, given the limited amount of information made available to them (Bloom, Shore, and Trelea- ven, 1979).

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Different states, of course, have taken different directions and have had various results regarding legal reforms. In Virginia, for example, the physi- cian is excluded from initial involuntary hospitalization decisions. Despite this fact, wrongful detention is felt to be rare, and nonexperts recognize the need for this procedure. Interestingly, psychiatrists’ ratings of the indications for in- voluntary hospitalization poorly predict the outcome of court hearings (Le- Buffe, Granger, and Wise, 1979).

Haupt and Ehrlich (1980) examine the effect of Pennsylvania’s new law on against-medical-advice discharges and recidivism. They find a tripling of the percentage of patients who leave against medical advice and show that these individuals are more frequently rehospitalized, require more emergency care, and more often fail to reach outpatient services. Munetz, Kaufman, and Rich (1980) have discovered that in Pennsylvania, from a clinical standpoint, the same kinds of patients continue to be committed, although there are some variations in the reasons specified. In addition, these authors tell us that there was an increase in the number of patients whose involuntary stay was length- ened subsequent to the new law - more hearings were requested and more ex- tensions granted (Munetz, Kaufman, and Rich, 1981). In Nebraska, there has been the paradoxical effect of increasing the total number of admissions, partic- ularly of the revolving-door type. At first, involuntary admissions dropped, but later increased, while the reverse held true for voluntary hospitalizations (Luckey and Berman, 1981).

The two states in which the effects of legal changes have been most ex- tensively studied are California and Massachusetts, Unfortunately for the pur- poses of this discussion, these same states were in the forefront of the deinstitu- tionalization movement from its inception. This complicates the interpretation of data relative to hospital populations. Lamb, Sorkin, and Zusman (1981) write that California’s pioneering legislative reforms have led to a change in the nature of the state hospital population (to more “hardcore” pa- tients), but not to a lower rate of involuntary admissions to such facilities. Clearly, society continues to have a need for social control, as my colleagues and I pointed out several years ago (Rachlin, Pam, and Milton, 1975). In the most comprehensive study of the results of changes in mental health law, McGarry (1981a) reports that a striking decline in the number of total and new admissions took place subsequent to the implementation of a new Massa- chusetts mental health law. Just as important is his conclusion (McGarry, 1981b) that the most profound changes have been those associated with proce- dural modifications. The major substantive difference, between an essentially parens patrim standard and that of likelihood of serious harm, has had little comparative influence.

In sum, for all the brouhaha, the total effect of statutory reform on de- institutionalization of the mentally ill remains inferential and not proven by thc data currently available. My conclusion, from reviewing the literature, is

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that there has been an acceleration in the pre-existing trends toward declining use of both involuntary commitment and the public psychiatric hospital.

It is also fair to conclude that the assistance of an attorney knowledge- able in mental health law is probably the single most important and funda- mental procedural right which can be granted. Patients frequently desire the services of a lawyer, especially with reference to hospital release (Epstein and Lowinger, 1975). The presence of lawyers has been shown to be the key to out-of-court settlements (Kumasaka, 1972). Largely by this route, the chance of discharge is markedly higher for those patients who request a hearing (Kumasaka, Stokes, and Gupta, 1972). Perlin reports (in press) that, where his legal advocacy service operates, judges consistently discharge over half of the patients who face commitment. This is all the more impressive because it is based on a review of more than 15,000 cases over a six-year period.

Just as dramatic are findings reported in a paper by Miller and Fiddle- man (1982). At their hospital, changes in only one or two attorneys created a major reversal in hearing outcomes. When an aggressive advocate for patient freedom was replaced by an attorney who saw the best interest of the patient as the guide, and the state’s lawyer began to bring families to hearings, many more physician recommendations for hospitalization were upheld, Addition- ally, the courts committed a greater percentage of patients even in the face of medical recommendations for release. It cannot be ignored that some of the consequences of legal intervention can be detrimental. I suggest elsewhere that attorneys develop a method of accountability in order to share a portion of the responsibility when something goes badly for the patient in court (Rachlin, 1981).

Litigation. The nation’s courts have also been quite active in the area of civil commitment. It is literally not possible to pick up an issue of the Mental Disability Law Reporter without reading about any number of court challenges and decisions respecting involuntary hospitalization. A summary of this mate- rial is beyond the scope of this chapter, but several crucially important federal cases require more than passing mention.

The first such major litigation was Lessardv. Schmidt. A three-judge dis- trict court held that the Wisconsin procedures for civil commitment were unconstitutional as being in violation of both substantive and procedural due process. The court ordered precise standards and stringent safeguards, based on a criminal law model, among which were notice and an opportunity to be heard, right to counsel, the privilege against self-incrimination, and the exclu- sion of hearsay evidence. Further, it was held that an extreme likelihood of immediate harm as a result of the mental illness, demonstrated by a recent overt act, had to be proven beyond a reasonable doubt. Despite the fact that this decision was twice vacated by the Supreme Court because of technical details, that it was never affirmed by that body, and that i t was ultimately ren-

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dered moot with the passage of a new state statute, its thinking has been quoted with approval in numerous subsequent cases in various jurisdictions and its influence has extended into the halls of many legislatures.

In 1975 the Supreme Court announced its decision in O’Connor v. Don- aldson. Other details are discussed below, but the principal holding in this case is generally agreed to be that a state, “cannot constitutionally confine without more a nondangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.” A right to liberty for the nondangerous mentally ill was determined to exist. Not to detract from this conclusion, we should also be aware that, in a footnote, the Court added, “a person is literally dangerous to himself if for physical or other reasons he is helpless to avoid the hazards of freedom.”

While it was at first thought that this decision would result in the release of large numbers of patients from mental hospitals, this has not proved to be the case (Kopolow, 1976; Sadoff, 1975). The main reason for the limited impact of Donaldson on the system of care delivery is the fact that so many of our long-term patients cannot survive safely in freedom and no longer have supports in the community (Rachlin, 1978). Empirical confirmation of this position is provided by Crane, Zonana, and Wizner (1977). They demon- strate that more patients were recommended for continued hospitalization under the Donaldson criteria because of their inability to function in any setting less confining than the state hospital than for any other reason.

T w o rulings of significance to the process of civil commitment of the mentally ill emanated from the Supreme Court in 1979. The first of these, Addington v. Tkxas, involved primarily the question of what standard of proof would be required in such proceedings. Because of the liberty interest, the Court said, more than a preponderance of evidence was necessary. However, “beyond a reasonable doubt” was not felt to be indicated because i t would erect an unreasonable barrier to hospitalization, a civil matter not to be equated with criminal prosecution. They settled on the intermediate standard of “clear and convincing” evidence as being constitutionally required. Elsewhere in the same decision, the Court said that the state has a legitimate parens patriue inter- est in providing for those emotionally ill persons who are unable to care for themselves, as well as the police power authority to protect the community from the dangerous propensities of certain mentally ill individuals. The Court went on to state, “one who is suffering from a debilitating mental illness and in need of treatment is neithcr wholly at liberty nor free of stigma.”

In Parham v. J . L. andJ. R., the Supreme Court was asked to determine what procedures were required with regard to the voluntary hospitalization of minors by their parents or guardians. Due process in this limited situation was concluded to require no more than some kind of inquiry by a neutral fact- finder who had the authority to admit or to refuse admission. It was held that

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this person could be a physician- that is, a judge or administrative hearing officer was not mandatory. Traditional medical investigative techniques, rather than adversarial proceedings, were felt to be sufficient for the making of this type of decision.

It is probably too early to tell what, if any, effect these pronouncements will have. One prime reason why it would be difficult to conduct research on this topic is that the Supreme Court sets minimum criteria required by the U.S. Constitution. State courts and legislatures are free to devise higher stan- dards if they so choose, or to leave intact their existing more stringent proce- dures. This has generally been the case. There has been no evidence of a great rush to change since Addington and Parham.

The Right to Treatment

The deceptively simple concept of a right to treatment was first intro- duced by Birnbaum in 1960. He defined it as the legal right of a patient in a public hospital to adequate medical and psychiatric treatment for his mental illness. By now, this concept is widely recognized as a moral imperative and is a feature of many state mental health laws. My colleagues and I have stated our belief that it is the most fundamental substantive right of mental patients (Rachlin, Pam, and Milton, 1975). In the courts, however, i t has fared less well.

In 1966, Judge Bazelon ruled in Rouse v. Cameron that the patient, hos- pitalized after a finding of not guilty by reason of insanity, had a statutory right to receive such treatment as would, in light of available knowledge, repre- sent a bona fide effort to alleviate his illness. The opinion went on to discuss a possible constitutional basis for the right, but did not so hold.

The first piece of class action litigation to state that involuntarily com- mitted civil patients have a constitutionally guaranteed right to treatment was that of Wyatt v. Stickmy. Judge Johnson wrote that the right to treatment was to consist of such individual attention as will give each patient a realistic opportu- nity to be cured or at least to improve his mental condition. Detailed standards were provided relative to staffing patterns and to such diverse concerns as laundry, mail, medication, and seclusion. However, thc basic building blocks on which treatment was to be provided were a humane psychological and physical environment, qualified staff in sufficient numbers to administer ade- quate treatment, and an individualized treatment plan for each patient. An account of the day-to-day realities of this litigation has been provided by the defendant, who, it must be said, in no way opposes a right to treatment (Stickney, 1977).

While this decision was upheld on appeal by the Fifth Circuit, that court did so based on its finding, just a few months earlier, in the Donaldson case, which was the first federal appellate ruling affirming the constitutional

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basis for a right to treatment. However, when Donalhon reached the Supreme Court, they found no reason to come to a decision about the right to treat- ment, but rather issued the more narrow ruling mentioned in the preceding section. In another footnote, the Court commented that its decision vacating the judgment of the Court of Appeals deprived that opinion of its precedential value. In light of this, it is curious to note the frequency with which Wyalt has influenced other courts as well as legislatures.

The constitutional basis of a right to treatment remains in doubt. Most legal authorities (Brooks, 1980a; Rosenzweig, 1980; Slovenko, 1981) contend that the Supreme Court’s decision in Donaldmn has negated the precedential ef- fect of the lower court’s holding, but Perlin (1976) believes that it may still be valid. It is clear from his concurring opinion that ChiefJustice Burger does not find any constitutional right to treatment; he is sharply critical of the concept.

Right to treatment litigation has hastened the process of deinstitution- alization (Slovenko, 1977; Stone, 1977). Indeed, Brooks (1979) sees deinstitu- tionalization as a less obvious but equally important objective of those attor- neys directly involved in such lawsuits. Certainly adequate treatment requires significant spending to upgrade in-hospital conditions. A partial solution to the fiscal dilemma would then be to discharge patients, in theory thereby reducing the costs of improvement (Rachlin, 1978). Implementing the right to treatment will always be expensive.

A brief comment on a related issue seems in order. The right to refuse treatment is often discussed alongside the right to treatment. Several years ago, I speculated that the right to refuse treatment might be an end-run device to eliminate civil commitment, given that hospitalization without treatment is not therapeutic but rather an imprisonment (Rachlin, 1975). This point of view has recently been echoed, with minor modifications, by Roth (1979, 1980) and Tanay (1980).

The Least Restrictive Alternative

An extension of the doctrine of the right to treatment is that it be pro- vided in the least restrictive environment. This latter principle has also found more favor in state legislatures than in the higher federal courts. One might well hypothesize that, in the final analysis, the right to treatment in the least restrictive setting may turn out to be of more value to the patient than the same right behind the walls of the state hospital.

The least restrictive alternative was first recognized by the U.S. Supreme Court in a case having nothing whatever to do with mental health. The Court held that legitimate governmental purposes may not be pursued in ways that broadly stifle personal liberties and that legislative abridgement of rights must be viewed in the light of less drastic means for achieving its intended purpose (Shelton v. Tucker).

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Again, it was Judge Bazelon who first introduced the concept of the least restrictive alternative to psychiatry. In the case of Lake v. Cameron, he ruled that the government had the burden of ascertaining if a type of cus- tody or place of confinement other than a mental hospital would be equally well suited to the needs of this particular patient, a woman with an organic brain syndrome secondary to cerebral arteriosclerosis. In a scenario all too frequently repeated to this day, it turned out that there were no available and appropriate alternatives for Ms. Lake, and she subsequently died in the hospital. The respective Lessard and Wyatt courts, among others, included requirements that treatment be provided in the least restrictive environ- ment. Legal experts who have written on the subject agree that the Supreme Court, by its reference to Shelton in the Donaldson decision, may have indi- cated its readiness to support a least restrictive tenet as being constitution- ally required for the treatment of the mentally ill (Brooks, 1980a; Rosenzweig, 1980).

Although neither an appellate nor a constitutional decision, Dixon v. Weinberger held that there was a statutory responsibility on the government to place patients outside of the hospital if that is where they were determined to belong. If no such less restrictive alternative environments existed, then a plan would have to be devised to develop the needed facilities. The force and influ- ence of this case is diminished by the fact that, some years later, the issues re- main unresolved (Brooks, 1980b; Perlin, 1980).

Brooks (1980a) sees the least restrictive environment as another strat- egy aimed at deinstitutionalization. Since hospitals are generally considered restrictive, the use of these facilities is circumscribed by the application of the doctrine of least restrictive alternative (Slovenko, 1977). My own feeling is that, if carried too far, the least restrictive doctrine is not always compatible with patients’ needs; we must strive to provide that degree of control which is therapeutically indicated (Rachlin, 1974). Perr (1978) cautions against inap- propriate extension of the least restrictive concept, suggesting that the most beneficial alternative for the patient considers restrictiveness as but one factor in the treatment plan. Also seeking the somewhat elusive most therapeutic option, Bachrach (1980) dissects three unwarranted assumptions involving the least restrictive environment: that the quality of restrictiveness lies outside the patient and in the environment; that it is primarily a function of the class of facility; and that it is related to residence, along a continuum rather than within a multidimensional matrix.

It would be disingenuous of me to close this topic without mentioning some legal expansions on the principle. Couington v. Harris held that the least restrictive environment was applicable, post-commitment, to wards within a hospital. A divided Third Circuit Court of Appeals recently ruled, in the case of restraint for a mentally retarded individual, that not only the locus but also

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the type of treatment has to be justified as least intrusive if it represents further deprivation of liberty (Romeo v. Youngberg). Finally, in the Kennie v. Klein right to refuse medication litigation, the determination by the District Court was that consideration had to be given to restrictiveness in deciding not only whether or not to medicate but also the type of psychopharmaceutical to be used. In a limited upholding of the decision, some of the judges of the Third Circuit again took occasion to question the applicability of least restrictive alternative to such treatment decisions. However, the First Circuit Court of Appeals in Rogers v. Okin has granted its seal of approval to possibly less restrictive means of therapy as a factor to be heeded. Since both Romeo and Rogm have already been argued before the Supreme Court, perhaps some additional answers will be forthcoming

The Horizon

Despite what may transpire in the future relative to legal rights affect- ing deinstitutionalization of patients, some individuals may wish to remain hospitalized. English, Redmond, and Peele (1981) have concluded that to allow patients to refuse community placement is unwarranted legally and undesir- able clinically. In a similar vein, I have applied the label “involuntarily commu- nitized” to patients in this class, and have argued that the right to treatment must be extended to them since they are expected to function with fewer sup- port systems than they had in the hospital (Rachlin, 1974).

There has been little litigation on behalf of ex-patients, especially with regard to their rights to treatment and other governmental entitlements (Per- lin, 1980). Lamb (1981) discusses another source of difficulty: the intervention of advocates, allegedly on behalf of patients, in a short-term community-based alternative to acute hospital care. Acting irresponsibly, these activists have told patients that they have a right to remain in the facility longer than clini- cally necessary, have attempted to prevent discharges, and have suggested that patients not cooperate with treatment or preparation for discharge. Then they have threatened legal action against the program for lack of adequate dis- charge planning! The extremists have discovered the community, and most of us would hope that this kind of situation is not a harbinger.

While the various changes in law reviewed in this chapter have surely contributed to the rapidity of the deinstitutionalization movement and thereby helped rectify some past abuses and injustices, so too have they created new problems. In an era when mental health programming initiatives are increas- ingly constrained by limited fiscal resources, the challenge to utilize the system to obtain those rights for our patients which best serve their treatment needs, wherever they reside, increases. Legal, medical, and social service decisions affecting patients’ lives must all depart from this basic concern.

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Stephen Rachlin is chairman o f the department o f psychiatry and psycholou, Nassau County (New York) Medical Center; associate professor o f clinical psychiaty, School o f Medicine, State Uniuersig of N e w York at Stony Brook; and a diplomate tf the American Board o f Formsic Psychiatry.