James N Butcher - Psicologia Clinica

www.ablongman.com/butcher12e Aspectos legales controvertidos 

minoría, el abuso de sustancias y un historial delictivo pre- nición mucho más cercana a M´Naghte. Esta Ley tam-
vio, también estaban asociados con repetidas detenciones bién especifica que el trastorno mental debe tener un
después de su liberación. carácter grave, y que la defensa debe establecer de
manera explícita y convincente la locura de su defen-
Llegados a este punto, hay que decir que hemos estado dido, lo que contrasta con la exigencia previa de que
utilizando el término alegato de locura con cierta impreci- era la acusación la que debía demostrar que el acusado
sión. Por tanto debemos estar más atentos a los múltiples estaba sano cuando cometió ese acto.
matices legales implicados en la cuestión. Los precedentes
sobre la alegación de locura son los siguientes: Este giro en la obligación de probar el alegato de locura ha
sido adoptado en muchos estados a partir del caso Hinc-
1. El fallo M´Naghten (1843). Bajo esta Ley, que suele kley. La intención de esta reforma es hacer menos atractivo
denominarse «el derecho a equivocarse», se supone el uso de este alegato, y parece que se ha conseguido (Stead-
que las personas están sanas a menos que puedan pro- man et al., 1993).
bar que cuando cometieran el acto se encontraban en
un estado de enfermedad mental, y que por lo tanto no Silver (1995) ha encontrado que el éxito del alegato
conocían la naturaleza del acto que estaban realizando depende del Estado. También informa que la duración del
—o, en caso que supieran que estaban cometiendo ese tiempo de confinamiento está más relacionado con la gra-
acto—, no sabían que era algo maligno. vedad del delito que con el hecho de que el abogado haya
recurrido al alegato de locura. Un estudio (Cirinclone, Ste-
2. El fallo del impulso irresistible (1887). Un segundo pre- adman y McGreeve, 1995) encontró que este alegato tenía
cedente en la alegación de locura es la doctrina del más probabilidad de alcanzar el éxito si estaba presente uno
«impulso irresistible». Esta perspectiva mantiene que o más de los siguientes factores:
el acusado podría no ser responsable de sus actos,
incluso aunque supiese que lo que estaba haciendo • Un trastorno mental, sobre todo un trastorno mental
estaba mal, si no tenía en ese momento la capacidad de grave
elegir entre el bien y el mal. Esto es, si no pudo evitar
cometer ese acto, debido a que estaba impelido a come- • El acusado es una mujer
terlo más allá de su voluntad (Fersch, 1980). • El delito no es un asesinato
• Se han producido hospitalizaciones mentales previas
3. El fallo Durham. En 1954, el juez David Bazelon, en una
decisión del Tribunal de Apelación de Estados Unidos, Hay tres estados —Idaho, Montana y Utah— que han abo-
amplió todavía más el alegato de locura. El juez no lido por completo el alegato de locura como estrategia de
creía que los precedentes anteriores permitiesen una defensa —una solución draconiana que compensa en clari-
aplicación suficiente del conocimiento científico de la dad lo que se pierde en compasión.
enfermedad mental, y propuso realizar un examen
basado en este conocimiento. Así pues su fallo, que Como hemos visto, con la expansión de la clasificación
suele conocerse como «el examen del producto», esta- diagnóstica de los trastornos mentales, es posible conside-
blece que el acusado «no es criminalmente responsable rar muchas más conductas como trastorno mental, como
de su acto delictivo si éste ha sido consecuencia de una sucede con el trastorno de estrés postraumático (Garrison,
enfermedad mental». 1998). ¿Qué enfermedades mentales sirven como excusa
para eludir la responsabilidad criminal? Generalmente,
4. El criterio del Instituto Legal Americano (1962). Cono- bajo el fallo M´Naghten, los trastornos psicóticos eran la
cido habitualmente como el «examen de capacidad base del alegato de locura, pero con los criterios Durhan y
sustancial» para la locura, este examen combina el del Instituto Legal Americano, también es posible recurrir a
aspecto cognitivo de M´Naghten con la consideración otros trastornos, como el de personalidad o el disociativo.
volitiva del impulso irresistible, al mantener que la per-
sona que perpetró un delito no puede ser legalmente Así pues, ¿cómo es posible determinar la culpabilidad
responsable, si en el momento del acto, y debido a una o la inocencia? Muchos expertos están convencidos de que
enfermedad o defecto mental, carece de «capacidad el alegato de locura plantea al tribunal una tarea imposi-
sustancial» para darse cuenta de su carácter delictivo, o ble: determinar la culpabilidad o la inocencia por causa de
para adaptar su conducta a las exigencias de la ley. locura a partir de un testimonio psiquiátrico. Reciente-
mente Perlin (1996) ha informado de que actualmente
5. La Ley De Reforma de la Alegación De Locura. En 1984 existe un elevado consenso entre los expertos en relación a
el congreso de los Estados Unidos adoptó este criterio la cordura del acusado; en algunos casos, se ha producido
respecto a la alegación de locura para que fuese apli- un testimonio conflictivo, debido a que la acusación y la
cado en toda la jurisdicción federal, aboliendo así el defensa han aportado su propio panel de expertos (Mar-
elemento volitivo del criterio del Instituto de Leyes vit, 1981).
Americano, y modificando el aspecto cognitivo, que
quedaría en «incapaz de apreciar», dejando así la defi- Podría ocurrir que la noción de no culpable por causa
de locura, aunque sea defendible y humana en cierto sen-

 C A P Í T U L O 1 8 Aspectos legales contemporáneos en psicología clínica

tido abstracto, tenga tantas lagunas conceptuales y de pro- Segunda Guerra Mundial la preocupación por los trastor-
cedimiento, que sea necesario reconsiderar seriamente su nos mentales llamó la atención del público cuando un gran
situación. Mientras tanto, lo más inteligente sería mante- número de jóvenes —dos de cada siete reclutas— eran
ner criterios muy estrictos al respecto (véase Steadman et rechazados del servicio militar por motivos psiquiátricos.
al., 1993). Este hecho trajo consigo una diversidad de medidas desti-
nadas a afrontar el problema de la salud mental de la nación.
Por último, hay que decir que en algunos estados se ha
adoptado el veredicto de culpable, pero mentalmente EL GOBIERNO FEDERAL Y LA SALUD MENTAL. En
enfermo (Borum y Fulero, 1999). En tales casos el acusado 1946, conocedor de las necesidades de más investigación,
puede ser sentenciado, pero internado en una institución enseñanza y servicios en el ámbito de la salud mental, el
mental y no en una prisión. Este tipo de decisión salomó- Congreso aprobó su primer Proyecto de Ley de Salud Men-
nica sirve para impedir la situación en la que una persona tal y la Ley Nacional de Salud Mental. En ese mismo año, se
comete un asesinato, se le considera no culpable por causa creó en Washington D.C. el Instituto Nacional de Salud
de locura, se le ingresa en una institución mental, allí poste- Mental. Su objetivo era actuar como un centro de investiga-
riormente se le encuentra cuerdo y no necesitado de trata- ción y enseñanza, y como cuartel general de un programa
miento, y queda libre tras un mínimo periodo de diseñado para impulsar la investigación y la enseñanza por
confinamiento. Sin embargo, con el veredicto de culpable toda la nación, para ayudar a los estados a mejorar y
pero mentalmente enfermo la persona permanece bajo cus- ampliar sus propios servicios de salud mental. El Congreso
todia de la institución mental hasta que cumple toda la sen- autorizó al Instituto a proporcionar fondos para proyectos
tencia. Marvit (1981) ha sugerido que esta estrategia podría de salud mental, destinados a estudios experimentales, pro-
suponer «un equilibrio realista entre los derechos del delin- yectos piloto, encuestas e investigación general. En la actua-
cuente con un trastorno mental, y la necesidad de la socie- lidad este Instituto se halla bajo los auspicios del Instituto
dad de controlar la conducta delictiva» (p.23). Nacional de la Salud, dentro del Departamento de Salud y
Servicios Humanos.
REVISIÓN
El Instituto Nacional de la Salud Mental (1) realiza y
• ¿Qué condiciones deben cumplirse para que promueve la investigación sobre los aspectos biológicos,
una persona pueda ser internada en contra de psicosociales y socioculturales, de los trastornos mentales;
su voluntad en una institución mental? (2) apoya la enseñanza dirigida a profesionales del ámbito
Describa el proceso legal que hay que seguir. de la salud mental; (3) contribuye a planificar, establecer y
mantener programas de salud mental más eficaces; y (4)
• ¿En qué consiste el alegato de locura? proporciona información sobre la salud mental, tanto al
público como a la comunidad científica. Hay otros dos ins-
• ¿Qué implicaciones tiene para los clínicos la titutos supeditados —el Instituto Nacional para el Abuso
decisión Tarasoff? del Alcohol y el Alcoholismo y el Instituto Nacional para el
Abuso De Fármacos— que realizan funciones similares en
ESFUERZOS ORGANIZADOS esos campos más especializados.
PARA LA SALUD MENTAL
Si bien el gobierno federal proporcionó liderazgo y
El conocimiento por parte del público de la magnitud de los ayuda financiera, son los estados y las organizaciones loca-
problemas de salud mental, y el interés del gobierno y de los les las que el planifican y desarrollan la mayoría de los pro-
profesionales, ha promovido el diseño de programas que gramas del Instituto. Sin embargo, la mayoría de los
intentan obtener una mejor comprensión, un tratamiento gobiernos estatales y locales no han sido capaces de estable-
más eficaz, y una prevención a largo plazo. Los esfuerzos cer programas y recursos, debido a los recortes del apoyo
para mejorar la salud mental no sólo son aparentes en nues- federal. En consecuencia, se han reducido considerable-
tra sociedad, sino también en muchos otros países. mente muchos de los programas dedicados a la salud men-
tal, incluso aunque en realidad haya aumentado su
Esfuerzos en Estados Unidos necesidad. Existe gran incertidumbre respecto a en qué
para la salud mental medida los problemas de salud mental se incluirán en pos-
teriores revisiones de la política nacional de salud.
En los Estados Unidos, la responsabilidad primaria para
afrontar los trastornos mentales recae inicialmente en el ORGANIZACIONES PROFESIONALES Y DE SALUD
Estado y en las instituciones locales. Sin embargo, durante la MENTAL. Existe cierto número de organizaciones pro-
fesionales de ámbito nacional en el campo de la salud men-
tal. Se trata de la American Psychological Association
(APA), la American Psychological Society (APS), la Ameri-

www.ablongman.com/butcher12e Esfuerzos organizados para la salud mental 

can Psychiatric Association (APA), la American Medical sociales de la integración de personas con discapacidad en
Association (AMA), la Association for the Advancement of el entorno laboral (Kramer, 1998).
Behavior Therapy (AABT) y la American Association for
Social Work. Es necesario hacer más investigaciones sobre la iden-
tificación de factores específicos del riesgo de salud mental
Una de las funciones más importantes de este tipo de en situaciones laborales, pero ya sabemos (por ejemplo,
organizaciones es establecer y mantener unos elevados cri- Sauter et al., 1990) que hay importantes problemas que
terios éticos profesionales en el seno de cada una de sus suelen pasar desapercibidos, en las siguientes áreas y con-
áreas. Esta función incluye (1) establecer y revisar la ense- diciones de trabajo.
ñanza que se ofrece a los profesionales; (2) establecer crite-
rios y procedimientos para la acreditación de los programas 1. Carga y ritmo de trabajo. El factor crucial parece ser el
de enseñanza; (3) establecer criterios para la acreditación grado de control que tiene el trabajador sobre su ritmo
de clínicas, hospitales y otros servicios, y realizar inspeccio- de trabajo, más que la propia demanda de trabajo per
nes para comprobar el cumplimiento de esos criterios; y (4) se. El ensamblaje mecánico resulta especialmente
investigar los eventuales casos de conducta no ética y adop- arriesgado para la salud mental.
tar cuando sea necesario acciones disciplinarias.
2. Horario de trabajo. Los turnos rotatorios y el trabajo
Una segunda función esencial de estas organizaciones nocturno están asociados con un riesgo más elevado de
profesionales se refiere a la comunicación y el intercambio dificultades psicológicas.
de información, mediante congresos, simposios, reuniones
de trabajo, cursos de reciclaje, publicación de revistas cien- 3. Factores de estrés. La ambigüedad en el cargo (por
tíficas y profesionales, y otras actividades similares. Además, ejemplo la incertidumbre sobre quién tiene la respon-
estas organizaciones promueven programas educativos sabilidad de algo), es muy frecuente en el ámbito labo-
para llamar la atención sobre las necesidades de la salud ral y tiene un impacto muy negativo en la salud física y
mental, y atraer estudiantes a estas áreas. mental.

Una tercera función básica de estas organizaciones 4. Factores de inseguridad laboral. La sensación de insegu-
profesionales tiene que ver con problemas sociales contem- ridad sobre el futuro laboral afecta de manera adversa
poráneos, como por ejemplo presionar al gobierno local y a la salud física y mental.
nacional para que proporcione más servicios a las personas
sin hogar. Las organizaciones profesionales de la salud 5. Relaciones interpersonales. Una relación negativa entre
mental se encuentran en una posición magnífica para compañeros de trabajo aumenta de manera significa-
actuar como asesores de los problemas de salud mental. tiva el riesgo de reacciones psicológicas adversas.

RECURSOS DE SALUD MENTAL EN LA INDUSTRIA 6. Satisfacción en el trabajo. La insatisfacción en el trabajo
PRIVADA. Ciertos problemas personales, como el estrés está asociada con una mala salud mental, y a su vez
matrimonial u otros problemas familiares, el abuso de alco- ambas con tareas monótonas que apenas permiten cre-
hol o fármacos, dificultades financieras, o el estrés laboral, atividad, y no dan al trabajador la sensación de estar
pueden afectar de manera negativa al rendimiento y la contribuyendo al producto final.
moral de los empleados. Las dificultades psicológicas de los
empleados de una empresa pueden generar muchos proble- Muchas empresas han reconocido desde hace tiempo la
mas, como el absentismo, accidentes laborales, disminu- importancia de la salud mental del trabajador, y la necesi-
ción de la productividad y un elevado tránsito de personal. dad de fomentar el bienestar en el puesto de trabajo, si bien
El Instituto Nacional Para La Seguridad y la Salud Laboral es cierto que sólo recientemente están actuando en esa
ha reconocido que los trastornos psicológicos son una de dirección. En la actualidad muchas empresas han ampliado
los diez principales problemas de salud laboral (Millar, sus «obligaciones» hacia sus empleados para incluir ciertos
1990), mientras que además, el riesgo de sufrir problemas servicios psicológicos. Los programas de asistencia permi-
mentales relacionados con el trabajo aumenta a medida que ten proporcionar servicios de salud mental tanto a los
lo hacen ciertos factores económicos, tecnológicos y demo- empleados como sus familias.
gráficos (Sauter, Murphy y Hurrell, 1990). Desde la aproba-
ción de la Ley de Americanos con Discapacidades, las Esfuerzos internacionales en salud
personas con problemas psiquiátricos no pueden ser discri- mental
minadas laboralmente. Las empresas están obligadas a
modificar el lugar de trabajo para poder adaptarse a las La salud mental no sólo es un tema de interés en los Estados
necesidades de las personas con enfermedad mental. Aun- Unidos, sino también en el resto del mundo. De hecho,
que las empresas se quejan de que esta adaptación resulta muchos de los problemas de nuestra sociedad se amplifican
demasiado costosa, es posible obtener grandes beneficios en los países pobres, y en los que padecen un gobierno
represivo. La gravedad de los problemas de salud mental
queda patente en la estimación de la OMS de que los tras-
tornos mentales afectan a más de doscientos millones de
personas en todo el mundo, en parte por el problema de los

 C A P Í T U L O 1 8 Aspectos legales contemporáneos en psicología clínica

refugiados (Mollica, 2000). El reconocimiento de este la salud mental. Su objetivo es promover la cooperación
enorme trance ha impulsado la creación de diversas organi- internacional entre agencias gubernamentales y no guber-
zaciones internacionales, desde finales de la Segunda Gue- namentales, y en la actualidad participan en ella más de cin-
rra Mundial. A continuación vamos a describir brevemente cuenta países. La OMS le ha otorgado un estatus consultivo,
la Organización Mundial de la Salud y la Federación Mun- y asesora a las agencias de la ONU recolectando informa-
dial de Salud Mental. ción sobre la salud mental en todo el mundo.

LA ORGANIZACIÓN MUNDIAL DE LA SALUD. La La década de los 90 fue testigo de una sorprendente
OMS siempre ha sido consciente de la estrecha interrela- apertura, junto a la caída de lo que hasta ese momento
ción entre los factores físicos, psicosociales y sociocultura- habían sido insuperables barreras entre naciones. Gracias a
les. Algunos ejemplos pueden ser la influencia de ciertos este aumento del intercambio de ideas y cooperación, es de
cambios muy rápidos sobre la salud física y mental; la esperar que podamos asistir a una colaboración todavía
imposibilidad de lograr progresos importantes en la salud mayor en salud mental. Resulta vital que continúe esta coo-
mental, en aquellas sociedades con una gran proporción de peración internacional, compartiendo información y pers-
malnutrición, parásitos y enfermedades; y las frecuentes pectivas sobre salud mental.
barreras psicológicas y culturales para el restablecimiento
de programas de planificación familiar y salud pública REVISIÓN
(Rutz, 2001).
• ¿Cuál es el papel del Instituto Nacional de la
La OMS se creó después de la Segunda Guerra Mundial Salud Mental para promover la atención a los
como una organización dependiente de las Naciones Uni- enfermos mentales?
das, cuyo principal centro de interés era la enfermedad
física; gracias a esta organización se han realizado impor- • ¿Qué es la Agencia Nacional de la Salud
tantes progresos para la eliminación de antiguos azotes, Mental y cómo contribuye a la mejora de los
como la viruela o la malaria. Durante muchos años además, servicios de salud mental?
la salud mental ha supuesto una preocupación cada vez
mayor entre los Estados miembros. Los programas actuales • ¿Qué es la OMS?
de la OMS integran esta preocupación por la salud mental
dentro de otros problemas más amplios de salud y desarro- DESAFÍOS DE FUTURO
llo económico, a los que se deben enfrentar sus Estados
miembros (OMS, 1997). Aunque la cooperación internacional, en su
esfuerzo de comprender y mejorar la salud mental resulta
El cuartel general de la OMS está en Ginebra, aunque alentadora, los medios de comunicación nos enfrentan a
tiene distribuidas oficinas regionales en África, ambas Amé- diario con la amarga verdad de que todavía nos queda un
ricas, el sureste asiático, Europa, el Mediterráneo oriental y largo camino por recorrer, antes de que nuestros sueños de
el pacífico occidental. Así pues, sus actividades se extienden un mundo mejor puedan cumplirse. Son muchos los que
a zonas con entornos físicos muy diferentes, así como diver- cuestionan que los Estados Unidos o cualquier otra nación
sas organizaciones sociales y recursos para la salud mental. tecnológicamente avanzada pueden ser capaces de lograr
Sólo puede entrar en un país por invitación de su gobierno, una salud mental óptima para la mayoría de sus ciudadanos.
para ayudar a identificar las necesidades básicas de salud, y El racismo, la pobreza, la violencia juvenil, el terrorismo, el
colaborar con las autoridades locales, para planificar y desa- desarraigo de la población de los países en vías de desarrollo
rrollar los programas más apropiados. Cuando resulta via- y otros problemas sociales que contribuyen a los trastornos
ble, ofrece sus servicios durante varios años, para asegurar la mentales, a veces parecen realmente insuperables.
continuidad y el éxito de tales programas.
También nos afectan las cosas que ocurren en el resto
Otra importante contribución de la OMS ha sido la del mundo, tanto de manera directa como indirecta. La
elaboración de la Clasificación Internacional de Enferme- inestabilidad económica mundial, así como la posibilidad
dades (ICD), que permite a clínicos e investigadores de de destrucción del sistema de apoyo a la vida en nuestro
diferentes países utilizar un conjunto uniforme de catego- planeta alimentan nuestra ansiedad respecto al futuro. Los
rías diagnósticas. Como hemos visto en el Capítulo 4, la cla- enormes recursos que hemos gastado en programas milita-
sificación del DSM-4 se ha coordinado con la de la OMS res durante el último medio siglo para protegernos contra
(Sartorius et al., 1993). posibles amenazas han absorbido el dinero y la energía que
podría haberse empleado en solucionar las necesidades
LA FEDERACIÓN MUNDIAL PARA LA SALUD MEN- humanas, no sólo en Estados Unidos sino en cualquier otro
TAL. La Federación Mundial para la Salud Mental se
creó en 1948 como un congreso internacional de organiza-
ciones no gubernamentales y de personas preocupadas por

www.ablongman.com/butcher12e Desafíos de futuro 

lugar del mundo. Los escasos recursos de los que ahora dis- En el ámbito de la salud mental están abiertas muchas
ponemos para los problemas de salud mental nos impiden oportunidades para el personal entrenado. El trabajo social,
resolver los principales problemas derivados del abuso del la psicología clínica, la psiquiatría y otras actividades rela-
alcohol y las fármacos, de vivir sin casa, las familias rotas y cionadas con la salud mental, son muy reforzantes en
las escuálidas condiciones de vida en las que se desenvuelve cuanto a la realización personal. Además, hay muchas otras
mucha gente. ocupaciones, que abarcan desde la aplicación de las leyes, a
la enseñanza, pasando por el sacerdocio, que pueden
La necesidad de planificación desempeñar un papel esencial en la salud mental y el bie-
nestar de la gente. La preparación en alguno de esos campos
Parece imperativo realizar una planificación más eficaz a suele brindar la oportunidad de trabajar en clínicas e insti-
nivel local, nacional e internacional, si queremos ser capa- tuciones similares, para obtener experiencia en la compren-
ces de reducir o eliminar los problemas de salud mental. Es sión de las necesidades y los problemas de las personas con
necesario enfrentarse a muchos desafíos si queremos crear estrés y familiarizarse con los recursos disponibles para su
un mundo mejor, tanto para nosotros como para genera- tratamiento.
ciones futuras. Sin cejar en nuestro esfuerzo por solucionar
nuestros propios problemas, también es esencial participar También los ciudadanos pueden encontrar múltiples
con más entusiasmo en las medidas internacionales dirigi- maneras de colaborar de manera directa, si están familiari-
das a disminuir las tensiones, y a promover la salud mental zados con los recursos y programas nacionales e internacio-
y un mundo mejor. A la misma vez, es de esperar que las nales, y si invierten el esfuerzo necesario para aprender
medidas adoptadas para reducir los conflictos internacio- cuáles son las necesidades y los problemas especiales de su
nales y mejorar las condiciones generales del ser humano, comunidad. Sea cual sea su papel en la vida —estudiante,
permitan hacer una contribución significativa a nuestro profesor, policía, abogado, amo de casa, ejecutivo o sindica-
propio progreso social y nacional, y a nuestra salud mental. lista— son sus propios intereses los que están en juego. Y es
que aunque la salud mental de una nación se pone de mani-
Tanto en nuestro propio país como en el resto del fiesto de muchas maneras —en sus objetivos, su coraje, su
mundo industrializado, los avances para prolongar la vida, responsabilidad moral, sus logros científicos y culturales y
conllevan otros problemas relativos a trastornos asociados su calidad de vida— en realidad su salud y sus recursos pro-
con una edad avanzada, sobre todo en el ámbito de la ceden en última instancia de las personas que viven en ella.
enfermedad de Alzheimer. A juzgar por el número de per- En una democracia participativa, son ellos los que planifi-
sonas que ya están afectadas, no sabemos si seremos capa- can e incrementan los objetivos nacionales.
ces de erradicar esta amenaza antes de que nos destruya.
Por lo tanto, la planificación y la preparación parecen nues- Además de aceptar cierta parte de responsabilidad en la
tra única esperanza racional para superar un potencial salud mental de los demás, mediante la calidad de nuestras
desastre de una magnitud sin precedentes; es necesario propias relaciones interpersonales, también existen otros
comenzar ya. cursos de acción, abiertos a cada ciudadano. Estas posibili-
dades incluyen (1) servir como voluntario en un hospital
La contribución individual mental; (2) apoyar medidas realistas para asegurar que
todos los grupos de edad puedan recibir servicios globales
La historia de la psicología clínica proporciona ejemplos muy de salud; y (3) trabajar en pro de la mejora de la educación
notorios de personas cuyos esfuerzos han sido fundamenta- pública, de un gobierno responsable, de la eliminación de
les para modificar nuestra manera sobre ciertos temas. los prejuicios y el establecimiento de un mundo más armo-
Recuérdese que Pinel eliminó las cadenas, Dorotea Dix inició nioso y saludable.
un movimiento para mejorar la situación de los hospitales
mentales y Clifford Beers inspiró el moderno movimiento de Todos nosotros estamos preocupados por la salud men-
salud mental, mediante su explicación autobiográfica de su tal por razones personales y también altruistas, y nos gusta-
experiencia con la enfermedad mental. Todavía no sabemos ría eliminar los desagradables problemas de la vida
quién será el que liderará la siguiente revolución en salud contemporánea y encontrar nuestra porción de felicidad en
mental. Lo que está claro es que mediante nuestro esfuerzo una vida plena de significado. Para ello, a veces necesitamos
individual podemos conseguir grandes avances. el coraje de admitir que nuestros problemas son excesivos
para nosotros. Cuando la existencia parece fútil, y avanzar se
Cuando los estudiantes se hacen conscientes del vuelve demasiado difícil, es necesario recordar los siguientes
enorme alcance del problema de la salud mental, tanto a hechos básicos, que son los que hemos ido destacando a lo
nivel nacional como internacional, así como de los recursos largo de todo el texto: de vez en cuando, cada uno de noso-
lamentablemente inadecuados para afrontar el problema, tros puede tener graves dificultades para afrontar los proble-
siempre suelen preguntar «¿qué puedo hacer yo?». Por eso mas de la vida. Durante esas crisis puede que necesitemos
parece adecuado sugerir algunas líneas de actuación que los ayuda psicológica. Ese tipo de dificultades no son una des-
estudiantes interesados pueden adoptar. gracia; le pueden ocurrir a cualquiera a condición de que

 C A P Í T U L O 1 8 Aspectos legales contemporáneos en psicología clínica

sufra un estrés lo suficientemente grande. La detección pre- Ningún hombre es una isla; cada hombre es una pieza del
coz y el tratamiento inmediato de las conductas inadaptadas continente, una parte del todo. Cada vez que el mar hace
son de enorme importancia para prevenir el desarrollo de desaparecer un terrón de tierra, Europa se queda un poco
problemas más graves o crónicos. Las medidas de preven- más pequeña, igual que si hubiese desaparecido un pro-
ción —primaria, secundaria y terciaria— son la estrategia a montorio, igual que si se hubieran ido un puñado de ami-
largo plazo más eficaz para la solución de los problemas de gos: la muerte de cualquier hombre me hace disminuir,
salud mental, tanto individuales como de grupo. porque yo soy parte de la humanidad, y por eso nunca pre-
gunto por quién doblan las campanas; doblan por ti.
Resulta esencial reconocer estos hechos, ya que las esta-
dísticas muestran que casi todos nosotros tendremos que REVISIÓN
enfrentarnos en algún momento de nuestra vida, con una
conducta gravemente inadaptada o con un trastorno men- • Escriba diversas formas en que los individuos
tal, ya sea en nosotros mismos o en alguien cercano. Nues- pueden contribuir al avance de la salud
tra interdependencia y la pérdida que supone para todos mental.
que alguien no sea capaz de lograr su propio potencial, apa-
recen elocuentemente expresados en estas líneas de John
Donne (1624):

TEMAS SIN RESOLVER

LA OMS Y EL CUIDADO DE LA SALUD MENTAL

Aproximadamente uno de cada tres americanos sufre tras- miento de la salud mental sea menos asequible y que su
tornos psicológicos que podrían precisar de un diagnóstico coste no suela ser reembolsado.
psiquiátrico (Regier et al., 1988), y alrededor de uno de
cada cinco recibe tratamiento (Castro, 1993). Se ha esti- En respuesta a estas necesidades, los administradores
mado que el tratamiento psiquiátrico supone la cuarta del sector de la salud han creado una gama de diferentes
parte de todas las plazas de los hospitales de América programas destinados a ofrecer servicios a un coste que la
(Kiesler y Sibulkin, 1987). Los gastos destinados a la salud sociedad se pueda permitir. Mediante la asistencia sanita-
en general están aumentando de una manera indirecta más ria dirigida, una red de empresas pone a disposición de una
rápidamente que cualquier otro factor de la economía esta- población determinada servicios hospitalarios, médicos y
dounidense (Resnick y DeLeon, 1995). Algunas empresas se otros proveedores/trabajadores (Resnick et al., 1994). Los
han gastado en la salud de sus empleados tanto como han proveedores de la asistencia sanitaria dirigida ofrecen asis-
ganado (O’Conner, 1996). Durante la anterior década, los tencia médica a un coste inferior mediante la restricción de
costes destinados a la salud subieron por las nubes debido los servicios tradicionales, el empleo de rigurosos procedi-
a que el número de personas que demandó estos servicios mientos de revisión, y la oferta de diferentes tratamientos
se incrementó en más del treinta por ciento por año (Giles, breves a bajo coste (Glazer y Gray, 1996). El modo de fun-
1993). La función de «puerta de contención» de las socie- cionamiento de estos sistemas es vender planes de asis-
dades médicas ha dificultado claramente el acceso a la tencia sanitaria a trabajadores o particulares que se
salud mental estadounidense, donde las decisiones corpo- inscriban en una empresa de servicios de salud o en una
rativas a menudo prevalecen sobre la necesidad del trata- sociedad médica mediante el prepago de una cuota fija que
miento. El tratamiento, una vez aprobado por las les da derecho a los servicios ofrecidos en ese plan (Res-
sociedades médicas, tiende a ser limitado tanto en duración nick et al., 1994). Estos programas disponen de personal
como en calidad. Como ya hemos visto en este capítulo, el médico distribuido en equipos de profesionales conocidos
tratamiento de la salud mental sirve tanto para prevenir como «comisión», que tienen la facultad y la capacidad de
como para apaciguar los trastornos mentales. Aún así, la suministrar una amplia variedad de servicios (Cummings,
actual crisis en el sector de la salud ha hecho que el trata- 1995). Algunas sociedades médicas —conocidas como equi-
pos de comisión abierta— dan a sus pacientes un margen

www.ablongman.com/butcher12e Términos clave 

de elección de sus proveedores médicos y permiten que cas. Las sociedades médicas que son conscientes del ele-
cualquier profesional cualificado dentro de la sociedad vado coste han empezado a ser consideradas por muchos
pueda participar. Sin embargo, la mayoría son equipos de expertos de campo de la salud mental como un simple
comisión cerrada, que limitan la selección de proveedores negocio en el que se niegan las necesidades del paciente
disponibles. Los beneficios varían de un plan a otro, y (Karon, 1995).
generalmente incluyen restricciones en la cobertura de
problemas o en la cantidad máxima de atención ofrecida o Terapia contrarreloj
de servicios disponibles. Para que los precios sean bajos,
algunas sociedades médicas operan de acuerdo a un sis- Los servicios de salud mental que ofrecen las sociedades
tema de «modelo capitativo», un modo de pago en el que el médicas tienden a apoyar programas más baratos y elabo-
proveedor de la asistencia sanitaria se compromete a ofre- rados menos cuidadosamente. Como cabe suponer, la far-
cer todos los servicios exigidos por la población mediante macoterapia es el tratamiento de salud mental que más
una cuota fija o tarifa plana por miembro inscrito o emple- prescriben. Cada año se receta a alrededor del diez por
ado (Richarson y Austad, 1994). La sociedades médicas ciento de la población estadounidense alguna medicación
asumen de este modo algún riesgo, pero el modelo capita- psicoactiva (Klerman et al., 1994). Curiosamente, en la
tivo puede suponer un gran beneficio si la cuota de la ins- actualidad son los pediatras los que recetan la mayoría de
cripción se puede fijar más cara que el coste de los la medicación psicotrópica, en lugar de los psiquiatras
servicios sanitarios. (Brody, 1996). Algunos sistemas de asistencia sanitaria diri-
gida han defendido el uso extendido de las terapias somáti-
Tratamiento de salud mental ¿quién cas para intentar reducir costes. Las intervenciones
decide de qué tipo y durante cuánto psicosociales, como la psicoterapia individual, se han desa-
tiempo? consejado o limitado a un escaso número de sesiones. La
psicoterapia a largo plazo ha sido virtualmente eliminada
En un primer intento para reducir los costes relacionados para todo el mundo excepto para unos pocos clientes ricos
con la salud, la agencia de asistencia sanitaria dirigida y privados (Lazarus, 1996). En cambio, la psicoterapia de
negocia un precio reducido directamente con el proveedor grupo se suele promover y fomentar porque normalmente
del servicio sanitario. Después, el proveedor factura a la se considera rentable.
sociedad médica por el tiempo empleado y a cambio le
brinda servicios profesionales «a bajo coste» (Richardson La mayoría de las empresas dedicadas a la asistencia
y Austad, 1994). Este enfoque supone un pequeño riesgo dirigida ofrecen un modelo de salud mental centralizado,
económico para el proveedor. Tal y como le podría parecer breve e intermitente. Aquellos que requieren tratamientos
a cualquier observador casual de los sistemas de asisten- más largos o necesitan ingresar en el hospital, por norma
cia sanitaria, los procedimientos para determinar los general, no suelen estar satisfechos con estas organizacio-
honorarios de los proveedores han supuesto siempre un nes. De hecho, las organizaciones de asistencia sanitaria
quebradero de cabeza para los profesionales de la salud dirigida suelen desaconsejar los tratamientos de salud
mental —psicólogos y psiquiatras (Resnick et al., 1994). El mental a largo plazo. Por ejemplo, la mayoría de los grupos
representante de la sociedad médica o el que actúa como de asistencia dirigida sólo aprueban estancias cortas en el
«puerta de contención» ante el reembolso, normalmente hospital (menos de diez días) y tratamiento de salud mental
un médico de medicina general sin experiencia en trastor- de cuatro a seis consultas externas en cada periodo. Son
nos psiquiátricos o en intervenciones psicosociales, con- pocas si se tiene en cuenta que la cantidad y tipo de servi-
trola el acceso a la terapia y a veces el tipo de cios que se ofrecen están directamente relacionados con
tratamiento a ofrecer (Resnick et al., 1994). En algunos criterios empíricos. Las decisiones sobre si tener ocho o
sistemas de asistencia dirigida, el controlador de la veinte sesiones de psicoterapia, por ejemplo, son arbitra-
puerta podría ser un empresario que, según la opinión del rias y a menudo parecen depender del capricho del médico
proveedor del servicio sanitario, bloquea el tratamiento o del paciente (Harwood et al., 1997).
adecuado haciendo que el médico tenga que justificar
periódicamente sus decisiones a alguien con poca o nin- Se ha producido una clara división entre los proveedo-
guna experiencia en salud mental. En tales situaciones res y directores de los servicios sanitarios. Los servicios
surgen problemas frecuentemente, pudiéndose estar pri- disponibles se suelen regir por criterios económicos más
vando a los pacientes de los apropiados y necesarios cui- que por el dictamen de un profesional de la salud mental.
dados (Resnick et al., 1994). Como consecuencia, los médicos están escandalizados por
la situación. Un psicólogo (Sank, 1997) sugería reciente-
Los programas de asistencia dirigida varían enorme- mente que se deberían fichar, con cargos éticos, a aquellos
mente en el modo y en la calidad de los servicios de salud profesionales de la salud mental que violen el acuerdo de
mental que ofrecen. Aunque su supuesta intención es ofre- confidencialidad paciente-terapeuta y revelen el proceso de
cer los tratamientos más efectivos disponibles, en el terapia a las sociedades médicas. Se han puesto algunos
momento de decidir cuáles ofrecer se basan habitualmente pleitos a las sociedades médicas por no cumplir con el
más en intereses económicos que en prescripciones médi- suministro de los servicios necesarios y apropiados. Es pro-
bable que las organizaciones de asistencia dirigida se

 C A P Í T U L O 1 8 Aspectos legales contemporáneos en psicología clínica

enfrenten a quejas por negligencia como resultado de su dos Unidos va a parar a la administración de la asistencia
publicidad legal y de la obligación de la prestar los servicios dirigida.
ofertados (Benda y Rozovsky, 1997).
La revolución en la asistencia sanitaria ha creado una
Los críticos se quejan de que en la asistencia dirigida fuerte polémica en el campo de la psicoterapia. El de la
no hay una clara evidencia de que los costes se estén con- salud mental está cambiando drásticamente por motivos
trolando realmente (Gabbard, 1994; Harwood et al., 1997) y económicos. Algunos psicólogos y psiquiatras independien-
que tampoco hay un apoyo científico para las opciones de tes han abandonado su profesión porque la psicoterapia no
beneficio limitado que se están llevando a cabo. Algunos les da para vivir. Es probable que estas dificultades cada
han destacado que los costes administrativos de los cen- vez mayores continúen mientras nuestra sociedad intenta
tros de asistencia dirigida (incluidos los salarios de los aceptar el coste de la asistencia sanitaria y se asegura de
directivos de las sociedades médicas) son exorbitantes. que está disponible. Una cosa es cierta: el entorno de las
Gabbard (1994), por ejemplo, calculó que aproximadamente profesiones relacionadas con la salud mental está cam-
la cuarta parte del presupuesto de las ambulancias de Esta- biando.

SUMARIO

• Muchos profesionales de la salud mental no sólo voluntad de la persona. Además, deben existir
intentan solucionar los problemas de salud mental, pruebas de que el individuo supone un peligro para
sino también prevenirlos, o al menos reducir su sí mismo o para la sociedad.
efecto.
• No resulta nada fácil, ni siquiera para
• Es posible concebir la prevención a partir de tres profesionales muy preparados, determinar
niveles: (1) intervenciones universales, que con antelación si una persona puede representar
intentan reducir las consecuencias a largo plazo un peligro para sí misma o para los demás.
de haber tenido un trastorno; (2) intervenciones Sin embargo, con mucha frecuencia los
selectivas, destinadas a atenuar la posibilidad de profesionales se ven obligados a realizar este
un trastorno e impulsar una salud mental positiva tipo de juicios.
en poblaciones de riesgo especial;
(3) intervenciones indicadas, que intentan reducir • Algunos fallos judiciales recientes han
el impacto o la duración de un problema, cuando achacado responsabilidad al profesional, cuando
éste ya se ha producido. su paciente ha causado daño a otra persona.
La decisión Tarasoff defiende que un terapeuta
• Durante los últimos treinta años, con la llegada de tiene la obligación de proteger a las posibles
nuevos psicofármacos y la modificación de la víctimas, cuando el paciente ha amenazado con
filosofía de tratamiento, se ha producido un matarlas.
importante esfuerzo para insertar a los pacientes
psiquiátricos en el seno de la sociedad. • El alegato de locura es un aspecto trascendental
de la psicología forense. Muchos profesionales de
• Se ha producido una enorme controversia sobre la la ley y de la salud mental, así como periodistas y
desinstitucionalización, y su fracaso para ofrecer legos en la materia, han cuestionado la utilización
un adecuado seguimiento a esos pacientes dentro que se está haciendo de este tipo de alegación.
de la comunidad.
• El precedente legal original, la norma M´Naghten,
• Los últimos trabajos en el ámbito de la atención mantiene que en el momento de cometer el acto,
post tratamiento de los pacientes mentales el acusado debía haber estado actuando lo
permiten establecer líneas de trabajo para realizar suficientemente fuera de sus cabales, como para
un seguimiento terapéutico. no ser consciente de la naturaleza de sus
acciones, o no saber que lo que estaba haciendo
• El hecho de ser un «enfermo mental» no es motivo estaba mal.
suficiente para ser internado en contra de la

www.ablongman.com/butcher12e Términos clave 

• Las ampliaciones más recientes del alegato de Abuso de Fármacos y El Instituto Nacional para el
locura, como puede ser los criterios del Instituto Abuso del Alcohol y el Alcoholismo, están
Legal Americano, han dejado abierta la posibilidad dedicadas a promocionar la investigación, el
de que personas que no están diagnosticadas de entrenamiento y los servicios de salud mental a la
psicóticas puedan alegar locura transitoria. comunidad.

• El éxito de John Hinckley al alegar locura • Ciertos profesionales y organizaciones de la
transitoria después de intentar asesinar al salud mental, así como muchas empresas y
presidente Reagan generó una tormenta de asociaciones voluntarias, también actúan
protestas. Una reforma eficaz y ampliamente de manera muy activa para promover la salud
adoptada al respecto consiste en hacer que la mental.
responsabilidad de presentar las pruebas (de
locura) recaiga sobre la defensa. • Otras organizaciones internacionales, como la
OMS y la Federación Mundial de Salud Mental,
• Ciertas agencias federales, como el Instituto han contribuido a establecer programas de salud
Nacional de Salud Mental, El Instituto Nacional de mental por todo el mundo.

TÉRMINOS CLAVE

Alegato de locura (p. 616) Desinstitucionalización (p. 609) Programas de aprendizaje
Culpable pero mentalmente Intervenciones indicadas (p. 606) social (p. 608)
Intervenciones selectivas (p. 604)
enfermo (p. 620) Intervenciones universales (p. 602) Psicología forense (p. 612)
Decisión Tarasoff (p. 616) Terapian ambiental (p. 608)



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