The Limits of Change in Mental Health Law

Paul S. Appelbaum

Almost a Revolution: Mental Health Law and the Limits of Change

New York: Oxford University Press, 1994. 233pp. ISBN 0-19-506880-7 $34.95 hc

Review by

Stephen L. Golding

This volume represents revised versions of lectures given by Professor Paul Appelbaum, perhaps the most distinguished and scholarly forensic psychiatrist of our day. These essays represent his views on how the "mental health-law revolution" of the last two decades has and has not changed the functioning of the mental health system. Many aspects of the interaction between the mental health and legal systems are addressed, but the critical focus is upon involuntary civil commitment, Tarasoff [duty to protect] situations involving potentially violent clients, treatment refusal and the insanity defense. One cannot fault this choice of timely and important topics. However, consideration of the debate on the nature and limits of forensic expertise, which cuts across many of these issues, would have been a valuable integrative mechanism.

The essays uniformly share two great strengths: a) sensitive integration of clinical and legal perspectives; and b) a scholarly approach to the problems analyzed. With respect to integration, for example, clinicians working with clients who refuse psychotropic medication will learn a great deal about the therapist-client interpersonal dynamics that often underlie treatment refusal. Thus, in addition to learning about the scholarly and empirical research on treatment refusal, as well as the jurisprudential debates that surround the right to refuse treatment, attentive consumers will find themselves focussing on the multiple determinants of treatment refusal, including not only the psychopathology of the client, but also the ways in which clinical skill (or lack of it) can impact the creation as well as the resolution of a "refusal." Similarly, Appelbaum's analysis of other critical issues is accomplished with careful attention to the traditional legal, psychological and psychiatric literatures. I use the modifier "traditional" because Appelbaum's treatment of various issues focusses on the forensic literature and misses the opportunity to integrate and incorporate other relevant scholarly and empirical work or resources. For example, the influence of societal and personal attitudes and beliefs about mental illness, personal responsibility and the role of the justice system certainly contribute to the "limits of change" with respect to civil commitment, the prediction of dangerousness and the insanity defense, but these literatures are not integrated into the essays. Nevertheless, his excellent forensic scholarship is uniformly apparent. Finding what he has to say about specific issues is made difficult, however, by an uneven index and a maddening use of chapter footnotes with no integrated index of references. Thus, finding what he has to say about a particular legal case, clinical phenomenon, or scholarly study is difficult because of the structure of the index and the lack of any comprehensive indexing of cases and references. For example, a reader interested in the death penalty's relationship to the verdict of "Guilty but mentally ill" would find an entry in the index which points to a paragraph that highlights an empirical finding of no death penalties in a study of GBMI pleas in Georgia. One then needs to go to a chapter footnote to discover that some state supreme courts have upheld the constitutionality of the death penalty in the context of GBMI verdicts. One would, unfortunately, not discover that Georgia is one such state, although it does make the death penalty unconstitutional with a verdict of "Guilty but mentally retarded" [see Burgess v. State 450 S.E. 2d 680 (Sup. Ct. GA 1994)].

The overall excellence and informative value of these essays is also somewhat diminished by a generic omission that lies at the heart of the purpose of these essays. Appelbaum is at his best when he describes and documents the ways in which intended reforms have been inadequately "thought through," the ways in which various components of the overall mental health-law system interact, and the resulting nature of "unintended consequences." What he omits, however, is an attempt to integrate these observations by means of a systems theory of social change. While some might see such an effort as beyond the scope of these essays, it would seem logical to attempt to review the literature from community psychology, systems theory and political science (particularly with respect to the implementation and corruption of "reform" in other systems) and to apply those notions to his observations on "the limits of change." Granted, no one else has tackled that problem in this area and Appelbaum does not promise such an integrated theory in his Preface. Nevertheless, given his position, knowledge and experience, some tentative theoretical steps in that direction would seem appropriate.

In sum, this is an excellent collection of essays on the limits of mental health reform. Its primary strength is a scholarly integration of traditional forensic literatures in considering how various attempts at reform have and have not produced both intended and unintended consequences. The overall excellence is somewhat diminished by little attention to non-forensic literatures, a limited index, and not probing the difficult but penultimate issue -- can one produce a theoretical model that predicts the limits of change and allows one to design interventions to overcome those limits?

Information about the author

[Please obtain from dust jacket]

Information about the reviewer

Stephen L. Golding, Ph.

Department of Psychology

University of Utah

Office: 801-581-8028

Position:

Professor

Department of Psychology

Adjunct Professor of Law and Psychiatry

Registered Psychologist

State of Utah

Diplomate, American Board of Forensic Psychology

Professor Golding was President of the American Psychology-Law Society and Division 41 (Psychology and Law) of the American Psychological Association in 1991-1992. He received the Distinguished Contributions to Forensic Psychology Award from the American Academy of Forensic Psychology in 1994 and is President-elect of the Forensic Division of the Utah Psychological Association.

Roesch, R., & Golding, S. L. (1981). Competency to stand trial. Urbana, IL: University of Illinois Press.

Golding, S. L. (1992). The adjudication of criminal responsibility: A review of theory and research. In D. K. Kagehiro & W. S. Laufer (Eds.) Handbook of Psychology and Law. New York: Springer-Verlag, Pp. 230-250.