Book Review

Back to the Asylum: The Future of Mental Health Law and Policy in the United States

N Engl J Med 1993; 328:892-893March 25, 1993

Article

Back to the Asylum: The Future of Mental Health Law and Policy in the United States
By John Q. La Fond and Mary L. Durham. 266 pp. New York, Oxford University Press, 1992. $39.95. ISBN: 0-19-505520-9

La Fond and Durham, respectively an attorney and a social scientist, have written widely on issues related to mental health law and policy in the United States. This book focuses on these matters as they have changed direction during the past 30 years and offers a forecast of further developments as we move into the 21st century. The authors divide the period into the “Liberal Era,” which lasted from 1960 to 1980, and the “Neoconservative Era,” from 1980 to the present. As with any public-policy issue, there is wide overlap between the eras, with dramatic changes in the activity of the courts, the views of the public, the interpretations of public officials, and the clinical decisions of mental health professionals in the public system. Appropriately, the authors focus on the two major issues of criminal responsibility and involuntary commitment and discuss how actions and perceptions of these concepts changed from the end of World War II to current practice in psychiatry.

Reviewing this book was an interesting experience for one who could have been described by the authors as one of the Liberal Era reformers. I did not react to the book simply as an intellectual exercise. Rather, I was troubled by the authors' apparent preoccupation with control of the mentally ill in the light of society's, and particularly organized psychiatry's, interest in the control of mental illness. In their efforts to engage the reader, La Fond and Durham sometimes use what I considered excessive license in editorializing. For example, describing the Supreme Court decision in Jones v. United States by saying, “The Supreme Court has authorized states to confine insanity acquittees for life even if they commit minor crimes such as shoplifting,” is, I believe, misleading. The comment that “defendants could no longer shop around with impunity until they found an expert witness willing to give testimony favorable to their case” seems somewhat slanted; the statement that “psychiatrists had left the unglamorous custodial chores of asylums behind and gone into private practice” by the mid-1960s is not an accurate description of vocational choices in the psychiatric profession; and “judges most frequently followed professionals' recommendations to hospitalize patients even in the absence of adequate evidence that the criteria for civil commitment were met” seems to be an overly broad and, I think, unfair indication that most judges were unethical. The suggestion that reputable mental health professionals such as Bachrach, Talbott, and I endorse the concept of the return to the asylum as “embracing a switch to the rights of the majority at the expense of the rights of the minority” is not accurate. Most readers would see this proposal as an expression of genuine concern by such providers for the quality of life and safety of some of our most vulnerable fellow citizens.

There are some minor editorial glitches, such as the interesting (neo-Freudian) slip in the reference to the landmark 1974 case of O'Connor v. Donaldson (actually Donaldson v. O'Connor); the dating of the publication of DSM-III-R as 1980, instead of 1987; and the reference to “Chapter 4, the Jones Case,” which is actually discussed at some length in chapter 3.

In spite of my disagreement with some of the authors' interpretations and the way they quote with equal respect the media, refereed journals, politicians, distinguished members of the legal profession, including justices of the Supreme Court, and psychiatrists, Back to the Asylum is a worthwhile book. The reader can examine the extensive data the authors have provided, cut through some of the editorializing, and draw independent conclusions that may or may not be congruent with those of the authors. The introduction, the first chapter, and the penultimate chapter are largely editorial. The chapters in between are extensively annotated and, including notes, bibliography, and an effective index, there are almost a hundred pages for the serious reader to research. Having internally debated a number of issues with the authors through the body of the book, I was surprised that I found very little to disagree with in the section on the future.

In summary, Back to the Asylum is an interesting mixture of law, history, sociology, politics, philosophy and ethics, and clinical and administrative psychiatry. I believe it will interest specialists in any of those fields, but particularly those of us who have an interest in a combination of them. This is one of the more interesting books on the subject and is valuable both for its provocative style and for the wealth of data on related issues during the past 30 years. I recommend it.

Stuart L. Keill, M.D.
University of Maryland, Baltimore, MD 21201