People with serious mental illness appear to be capable of voting in
elections and understanding the value and importance of their vote, according
to a small study using a measurement tool that can be used when a person's
capacity to vote is called into question.
That was the finding from an assessment of capacity to vote of 52
community-dwelling people with serious mental illness, using the Competency
Assessment Tool for Voting (CAT-V). This instrument operationalizes the
criteria for capacity to vote established in a 2001 federal court decision.
That standard, known now as "the Doe standard," is based
on a person's ability to understand the nature and effect of voting.
The study appeared in the May Psychiatric Services.
"Overwhelmingly, a group of community-dwelling outpatients with
serious and chronic mental illness did very well when it came to their
capacity to understand the nature and effect of voting and to make a choice
about candidates in an election, which is the legal standard on which the
study was based," said study author and past APA President Paul
The CAT-V was developed by Appelbaum and colleagues Richard Bonnie, J.D.,
and Jason Karlawish, M.D., for a 2005 study of the capacity to vote of people
with Alzheimer's that appeared in the November 2005 American Journal of
The criteria used in the CAT-V are based on those established in a 2001
federal district court decision in Maine, Doe v. Rowe, which struck
down a provision in Maine's constitution that denied voting to people under
guardianship because of mental disabilities. In that decision, the Maine court
ruled that persons are considered incompetent to vote only if they "lack
the capacity to understand the nature and effect of voting such that they
cannot make an individual choice."
In the study using the CAT-V, respondents were asked to imagine it is
election day for the office of governor in their state and about the nature
and effect of voting. They were then asked three questions related to the
Doe standard, assessing ability to understand the nature of voting,
ability to understand the effect of voting, and ability to make a choice.
There were three additional items assessing comparative reasoning, ability
to generate consequences, and appreciation of the effect of a choice on one's
life. Participants were read descriptions of two candidates and asked to
choose one, and to compare the candidates and how choosing one would affect
their lives; they were also asked why they would or would not want to vote in
the next election for governor (see Determining Capacity to Vote for excerpt from the CAT-V).
Each question in the CAT-V is scored on a 3-point scale, with a score of 2
indicating adequate performance, a score of 1 indicating marginal performance,
and a score of 0 indicating clearly inadequate performance.
The 52 participants took an average of 7.8 minutes to complete the entire
interview. Ninety-two percent (47) scored either a 5 or 6—out of a total
6 possible points—on the three Doe-standard questions.
They performed equally well on the assessment of comparative reasoning, but
had more difficulty describing the impact of their choices on their own lives,
with 77 percent scoring the high score of 2 on the question assessing ability
to generate consequences. Moreover, the results did not correlate with
cognitive function, intelligence, or severity of symptoms.
"Many decisional tasks correlate with cognitive function,
intelligence, and severity of symptoms," Appelbaum explained."
That this wasn't the case in this study suggests that at least within
the range of impairments found in a seriously mentally ill outpatient sample,
the tasks associated with voting are simple enough that most people are likely
to be competent to vote. Had we found a correlation, that might have
identified a subset of patients—for instance, those who are more
symptomatic or have more cognitive problems—about whom there might be
"The bottom line is that standards for competence to vote are
not—and should not be—demanding, and hence within the usual range
of impairments found in a population with serious mental illnesses,
incompetence to vote will be rare," he said.
Appelbaum explained that most states have constitutional or statutory
provisions defining who can and cannot vote, and many of these are archaic,
denying voting rights to "idiots" or "insane persons."
These provisions are largely neglected, but the issue has risen to the surface
from time to time in certain high-profile cases, as when officials in Rhode
Island tried to restrict the voting rights of two people who had been ruled
not guilty of a crime by reason of insanity.
In Missouri a constitutional provision restricting voting by persons under
guardianship for mental disabilities was upheld in court because it was
interpreted as requiring individualized assessments of capacity to vote.
Appelbaum added that challenges to an individual's right to vote may be
more common in local elections, whose outcomes are often close.
He cautioned that the CAT-V, or any similar instrument, should not be used
as a routine screening tool, but may be useful in individual cases in which a
person's right to vote is being challenged.
"We have to be leery of efforts to use this instrument for wide-scale
screening of people with mental illness," he told Psychiatric
News. "The Americans With Disabilities Act, among other laws, and
probably the Constitution protect the rights of people with mental illness
from being treated differently from the rest of the population. We don't
screen the general population for their capacity to vote, so in general we
shouldn't be screening people with mental illness.
"The real utility of an instrument like this is when there are some
substantive grounds on which to worry about or challenge a person's capacity
to vote," he said. "When an individual decision needs to be made,
that's where this might be useful."
"The Capacity to Vote of Persons With Serious Mental
Illness" is posted at<http://ps.psychiatryonline.org>
under the May issue. ▪