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Almost a Revolution: Mental Health Law and the Limits of Change
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Paul S. Appelbaum. 233 pages. New York: Oxford Univ Pr; 1994. $34.95.
Mental health is not a sexy topic; mental health law is even less so. But psychiatrist Paul S. Appelbaum has written a chronicle and an analysis of the reforms made in mental health law in the 1970s and 1980s that grab your attention.
Examined in detail in separate chapters are the four most important reforms of that era: changes in civil commitment laws from standards basing involuntary hospitalization on the patient's need for treatment to laws with stringent procedural protections permitting confinement only if the patient is found dangerous to self or others; liability of mental health professionals for the foreseeable violent actions of patients; the development of a right of psychiatric patients to refuse treatment, particularly antipsychotic medication; and changes in the insanity defense in the wake of the John Hinckley, Jr., trial.
Of these, the chapter on civil commitment laws is probably the most interesting. Appelbaum's thesis, here and throughout the book, is that the more things change in mental health law, the more they stay the same. Although the changes seemed massive and revolutionary at the time, Appelbaum concludes that, over time, they had less effect on the functioning of the mental health system than was expected because of inherent flaws in the reforms, unanticipated resistance to the reforms, and the interplay of other social forces. Hence the title: Almost a Revolution.
With regard to civil commitment, the thesis seems to fly in the face of the evidence on the street corners of big- (and not so big) city America. But Appelbaum sees deinstitutionalization without simultaneous creation of community mental health services as "at least one plausible explanation, apart from strict commitment laws" for the number of homeless, mentally ill persons. Players in the system, he maintains, have gotten around the commitment laws to get people the help they need when they need it.
Whether you agree with the thesis or have a stake in the system, this is interesting reading.
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