Book Review

Health Care Politics

Almost a Revolution: Mental health law and the limits of change

N Engl J Med 1995; 332:196January 19, 1995

Article

Almost a Revolution: Mental health law and the limits of change
By Paul S. Appelbaum. 233 pp. New York, Oxford University Press, 1994. $34.95. ISBN: 0-19-506880-7

In the preface to Almost a Revolution, Dr. Appelbaum defines wisdom as an amalgam of many desirable traits, including understanding, but a special kind of understanding -- ``an understanding that allows one to apply one's understanding to effecting solutions in the living world, and a capacity to place things into perspective, to bring a body of experience to bear on new events, to discern their meaning and their likely implications.'' I have always thought of Dr. Appelbaum as a scholar and a wise man. His latest contribution only reinforces my opinion. To understand and explain the past 25 years of mental health law, the author has reviewed the revolution in the field from the perspective of research studies and on the basis of his own practical knowledge gleaned from working at the interface between the clinic and the court. He has brought to this knowledge his own marvelous capacity to place things into perspective. Dr. Appelbaum reports one of many lessons he has learned during two decades of observing, participating in, and studying the relation between psychiatry and the law. His message is clear: despite the push for reform from civil libertarians, legal scholars, practicing lawyers, and legislators, less has changed in the real clinical world than anyone at the junction of law and psychiatry would have predicted 25 years ago.

The author examines four of the most important reforms in mental health law that have occurred during the past two decades, involving involuntary hospitalization (civil commitment), the liability of professionals (psychiatrists) for violent acts committed by patients, the right to refuse treatment, and the insanity defense. He begins with a historical review of the law in each of these areas, then reviews the changes that have occurred. Next, he reports on the changes that attorneys and mental health professionals expected the reforms to produce. He then presents the empirical data that support or refute the predicted changes. Finally, he explains why the radical changes that reformers hoped for and clinicians feared did not occur.

Dr. Appelbaum speculates about the lesson for the future of mental health law. He suggests (and I believe) that extreme ideological positions are unlikely to lead to stable reforms. He notes that no single set of interests can or should command the allegiance of those who fashion mental health law and that the purpose of such law should be to achieve reasonable compromises between often conflicting desiderata. ``Compromise should be considered the goal of efforts to revise mental health laws, not a second best outcome.'' These mental health law reforms represent a compromise among the wishes of civil libertarians, philosophers, lawyers, clinicians, patients, families, and the public. The author also comments that when the law is changed, it is critical first to predict what changes will occur in the clinic, then to study changes, and finally to report on them using empirical data. ``Rational mental health law reform should involve deliberate experimentation by particular jurisdictions, with close examination of the consequences prior to a more widespread adoption.''

Dr. Appelbaum recognizes that judges, lawyers, family members, and the general public all conspire and collaborate to fashion an extralegal process to accomplish what they think is fair and just for persons with mental illness, while protecting the rights of patients, society, clinicians, and family members.

As usual, Dr. Appelbaum's thinking, writing, and logic are remarkably consistent and lead clearly to his conclusions. The scholarly paragraphs are enlivened by wry humor and clever comments that amuse the reader but never evoke guffaws. It is difficult to find humor in this complex area, but Dr. Appelbaum has managed to flavor his text with his own observations and insight.

No examination of the results of 25 years of reform will satisfy all readers. However, Dr. Appelbaum uses clinical examples to present his point of view, drawing on his own experiences and theoretical explanations. What more can a scholar do? I commend him and recommend this book to anyone interested in this cross-disciplinary field. I am sure I will use this book repeatedly in my teaching and practice over the years and will loan it to students and colleagues; I only hope they remember to return it.

Elissa P. Benedek, M.D.
University of Michigan Medical Center, Ann Arbor, MI 48104