Understanding Mental Health and Guardianship: Navigating Complexities Associated With Schizophrenia

Mental health is an integral part of one’s overall well-being, and when it deteriorates to a point where a person is no longer capable of making informed decisions or caring for themselves, the concept of guardianship comes into play. Guardianship is a legal arrangement through a special family court proceeding that allows a designated individual or entity to make decisions on behalf of someone who is unable to make those decisions for themselves due to a mental health condition or other incapacitating factors. Typically, guardianship is considered when an elderly family member is experiencing a decline in cognitive function most often associated with Alzheimer’s or dementia. However, there are numerous health conditions which may be related to or cause a significant loss in cognitive function across a diverse age range of individual for whom guardianship may be considered, including severe autism, cerebral palsy, down’s syndrome, and in mental health disorders such as schizophrenia, severe bipolar disorder, advanced dementia, or impairment of other cognitive functions. In this article, we will explore the intersection of mental health and guardianship, delving into the purpose, process, and ethical considerations surrounding guardianship, particularly in cases of complex mental health conditions like schizophrenia.

The Purpose of Guardianship.

Guardianship serves a crucial role in safeguarding the welfare of individuals who are unable to make informed decisions due to their mental health condition. The primary goal of guardianship is to protect the individual and ensure their well-being in various aspects of life, including healthcare, finances, and personal affairs. When a person loses the capacity to make decisions for themselves, they may be at risk of neglect, exploitation by others, or harm. Such harms can include the risk of financial exploitation or as a result of an inability to independently manage one’s own finances, becoming at risk of legal jeopardy in some manner and being unable to respond to the same, harm to one’s health including by self-harm or by being unable to understand or obtain access to healthcare, or any combination thereof. Guardianship steps in to fill this void by appointing a guardian who can act in the best interests of the individual, ensuring they receive necessary care, access to medical treatment, and financial security.

The Guardianship Process and Consent.

The traditional guardianship process often begins with concerned family members or legal representatives petitioning the court for guardianship when they perceive that a person may either be at risk or has a substantial need for the appointment of a guardian to oversee some aspect of a person’s life. The process of establishing guardianship involves several steps, which may vary by jurisdiction, but in Nevada typically includes the following:

• Evaluation: The individual will need to be evaluated by a physician or psychologist to determine the extent of incapacity, their ability to independently manage their activities of daily living, and generally provide an opinion as to whether guardianship is necessary or recommended. The Physician or Psychologist will provide a report, which must be filed with the Court to demonstrate there is a need for guardianship.
• Petition: Someone, often a concerned family member, friend, designated person or legal representative, initiates the guardianship process by filing the petition and the physician’s or psychologist’s report with the appropriate court. This petition outlines the reasons for seeking guardianship, provides evidence of the individual’s incapacity and need for guardianship, and provides information about the person in need of guardianship and the person(s) who seek to be appointed as guardian(s).
• Court Hearing: A court hearing is scheduled where the evidence presented is considered, and a judge makes the final decision regarding the need for guardianship. This decision includes designating the proper person to be appointed as guardian.
• Ongoing Monitoring: Guardianship is not a one-time decision. The court often requires the guardian to prepare a proposed budget for finances and a care plan for the individual’s health care and supporting their activities of daily living. The court will additionally require the filing of annual financial accountings and reports to ensure that the guardian is acting in the best interests of the individual.

This oversight helps maintain accountability and protect against potential abuse.

Ethical Considerations.

While guardianship serves a critical role in protecting those with severe mental health issues, it also raises ethical concerns, particularly related to individual autonomy and potential abuses of power by the guardian. It is essential to strike a balance between safeguarding the vulnerable and respecting personal rights. Key ethical considerations which are routinely considered include:

• Advance Directives: Given the substantial impairment of rights which may be involved, guardianship is typically treated as a last resort. Individuals should be encouraged to establish advance directives while they may be able to do so, including by establishing financial and healthcare powers of attorney, designating a representative healthcare agent for transmission and receipt of confidential healthcare information and records as may be required by HIPAA, establishment of advance psychological directives which may outline preferred treatment options and medication, advance designation of persons who may be preferred to be appointed as guardians, and estate planning. By establishing appropriate advance directives an individual can ensure that their preferences for future decision-making in the event they lose capacity are considered, and can help protect their autonomy and ensure their wishes are respected. Likewise, having appropriate advance directives and estate planning in place may make it so that guardianship is never needed in the first place.
• Least Restrictive Alternative: Guardianship should be the least restrictive alternative. In cases where a person’s capacity can be partially retained with appropriate support, alternatives like advance directives, supported decision-making, or power of attorney should be explored. Likewise, while an individual is under guardianship, when faced with often difficult decision-making involving an individual’s autonomy and freedom, the guardian should be guided by choosing among the options which are least restrictive of the individual’s autonomy or freedom. In this regard, several states including Nevada, have established a protected person’s bill of rights, which seeks to protect the individual’s independent decision-making and freedoms to the greatest extent possible.
• Advocacy: Guardians should act as advocates for the individual’s best interests rather than their own. This requires a high level of trust and ethical responsibility on the part of the guardian. Likewise, an individual’s family members are encouraged to participate in ongoing guardianship status and review hearings to ensure that the individual’s rights and best interests are being appropriately considered in all aspects of the guardianship.
• Regular Review: Regular court reviews and oversight are essential to ensure that guardianship remains necessary and that the guardian is fulfilling their duties properly. As an individual’s needs will change overtime, it is important for the guardian to regularly inform the court and family members about any material change in circumstances of any matters effecting the guardianship.

The Complexity of Schizophrenia.

Schizophrenia is a complex mental disorder characterized by distorted thinking, delusions, hallucinations, and impaired cognitive functions. It is essential to recognize that the experience of schizophrenia varies widely among individuals. Some may manage their condition effectively with medication, treatment and support, while others may face significant challenges in maintaining their autonomy and making informed decisions. Additionally, in the case of schizophrenia, a person’s capacity to make decisions may fluctuate. They may experience periods of lucidity where they can manage their affairs and make choices, only to be followed by times of acute symptoms and cognitive impairment. This complexity raises a critical question: should guardianship be imposed without the individual’s consent? Such question of consent is equally important when any individual is capable of making decisions during periods of lucidity, and which guardians must tread cautiously.

While guardianship serves a critical role in safeguarding those with severe mental health issues, it is imperative to recognize that a one-size-fits-all approach may not be suitable. The legal and healthcare systems must be flexible enough to adapt to the varying needs and capacities of individuals, while guardians must be given the appropriate resources to address those needs. The goal should be to protect those who genuinely need assistance while respecting the autonomy and consent of those who can make decisions for themselves during periods of lucidity. Unfortunately, guardianship proceedings can often be inflexible and slow to respond to urgent situations presented by individuals suffering from schizophrenia. For instance, in the time it takes to file a petition and obtain access to the court, the individual’s needs may have drastically changed, or they may be lucid again and capable of acting independently. Such individual’s needs may be beyond the court’s or guardian’s ability to address in a realistically beneficial manner or timeframe.
In such cases, it is crucial to explore alternative approaches that respect the individual’s autonomy while ensuring their well-being. This may involve:

• Supported Decision-Making: Instead of guardianship, a person with schizophrenia may benefit from supported decision-making arrangements. This allows them to retain more control over their life while receiving assistance from trusted individuals in making choices during times of incapacity.
• Advance Directives: Encouraging individuals with schizophrenia to establish advance directives is essential. These directives can outline their preferences for future decision-making, specifying under what circumstances they would want assistance or guardianship, and when they wish to retain control over their choices.
• Regular Review: Even in situations where guardianship is deemed necessary due to the severity of symptoms, it is essential that the court establishes a robust system for regular review. This process allows for reevaluation of the individual’s capacity and consideration of less restrictive alternatives, should their condition improve.

Conclusion.

In navigating the complex terrain of guardianship and mental health, it is essential to recognize that the experience of any individual will not be uniform. Guardianship may not always be appropriate, especially when individuals with schizophrenia or other disorder may have periods of lucidity and can make informed decisions regarding their care and treatment. Instead, a more flexible approach, including supported decision-making and advance directives, should be explored to protect autonomy while ensuring well-being. Ethical considerations play a crucial role in finding the appropriate balance between safeguarding the vulnerable while respecting individual consent. An attorney who is familiar with these concepts can help such persons and concerned family members understand their rights and options available.