Defining a clinically useful model for assessing competence to consent to treatment.

Burdened with the responsibility of making an initial assessment of their patients' capacity to make treatment decisions, clinicians need a sound clinical assessment model. Drawing on ethical, legal, and clinical sources, the author reviews the appropriateness of existing models and standards and describes why each fails the needs of the clinician. The patient's ability to form a therapeutic alliance is shown to be a valid assessment model for defining a treatment decision-making ability threshold because it adheres to widely accepted ethical and legal standards. Using threshold because it adheres to widely accepted ethical and legal standards. Using this model to set a threshold for the decision to bring cases to the attention of a court or administrative body, the therapist arrives at a satisfactory balance between competent treatment, patient autonomy, and judicially mandated due process imperatives while providing a forum for patient education and assessment of the clinician's technical skill. Explanations of case examples illustrate the use of the therapeutic alliance for this purpose in a variety of clinical situations. Specific recommendations are made on what may be represented to court in cases in which the patient's competence appears to fall below this treatment threshold.