Mental Health and Law: Research, Policy and Services

This book is edited by two people well-known in the field of forensic psychology. Indeed, the late Saleem Shah, a friend to so many of us in psychiatry, was a well-versed clinical psychologist as well as a senior research scholar at the National Institute of Mental Health until his death in 1992. A selected group of individuals contribute the chapters. In simply looking at the chapter topics, one would not discern any difference from those in a collection written by a group of psychiatrists. This congruence is interesting in its own right, for it raises questions as to what differences might be anticipated from a book of this type if it had been written by forensic psychiatrists rather than forensic and research psychologists. I raise this question not only because of the number of clinicians from both fields now gravitating toward the forensic area in an attempt to salvage some type of autonomy in their professional lives, but from a more theoretical or academic point of view. If any difference in the content of this volume is detected, it is in its emphasis as well as specific suggestions in some chapters on the need for research. It is not that the research is yet to come but that it seems increasingly necessary. Meanwhile, what we currently have are some very vexing questions that continue to pervade the area of mental health and the legal system and will continue to do so.

The perspective of the editors is that mental health law should be policy oriented and/or program oriented rather than discipline oriented. Thus, the approach is not to test a particular theory of a mental health discipline or a social science discipline but, rather, to ask how certain programs and services could be improved. This means that a need exists to provide a better understanding for the diverse ways that clinicians and legal professionals interact. Can therapeutic goals be integrated into the legal system? Can legislators create programs that are protherapeutic or at least minimize antitherapeutic elements? To accomplish such goals is always difficult because policy makers are ultimately politicians, who need to balance demands from many competing groups. To complicate matters, policy questions are often presented as if they were scientific ones. A prime example is in the enduring problem of predictions of dangerousness of the mentally ill, which arises in civil and criminal contexts. In her chapter on civil commitment, Mary Durham notes the paucity of high-quality research in the area of involuntary civil commitment; most studies are anecdotal or garden-variety accounts of hospital admissions before and after legal interventions. Similarly, in her chapter on involuntary outpatient commitment, Kathleen Maloy notes that the empirical studies that have been done in this hotly debated area have serious flaws.

Thomas Grisso has an interesting chapter on research; he makes recommendations that could improve clinical evaluations. The approach would use criteria for research on behaviors for which assessments are sought by courts. Hence, it would focus on the accuracy of clinical judgments about behaviors, factors related to the behaviors, and the factors clinicians actually rely on in arriving at their expert opinions for courtroom use. Marnie Rice, Grant Harris, and Vernon Quinsey observe that, although considerable funds are expended to assess responsibility for criminal offenses, the end result is often the long-term confinement of such people to hospitals, where life is little different than if they had been sent to prisons. Their thesis is that too many resources are expended on forensic assessment and too little on subsequent efforts at intervention. Although Dorothea Dix’s arguments in 1845 for additional funds to care for the seriously mentally ill sound the same as many current appeals, Jeffrey Rubin points out that the system we have today continues to be dominated by decisions made about financing the delivery of care, and that these decisions affect the quality of assessments in the forensic mental health system as well.

A decade ago, most of the statutes remaining on the books regarding sexual psychopathology were regarded as anachronisms—the state legislatures had simply not bothered to repeal them because they were so infrequently used. An interesting sociological question is what has led to the enormously increased concern and public focus on sex offenders. Some of this may be due to high-profile cases with their attendant publicity, but something more appears to have been operating in American society. The result is that states have gone back to using or creating special types of sex offender legislation. Attorney Jeffrey Klotz notes that the work on recidivism of sex offenders has usually been theoretical and methodologically weak. A therapeutic jurisprudence approach would inquire whether the legal system is having a therapeutic or antitherapeutic significance, with the law as an independent variable. However, therapeutic aspects are only one variable among many operating in mental health law because other variables, such as autonomy, budgets, integrity of fact finding, and public safety, are equally decisive.

The diverse topics covered in this volume are all standard fare for any psychiatrist working in the forensic area or for someone who is seeking a discussion of several key areas of law and mental health. A group that probably will not read this book but could benefit from it are attorneys, both practitioners and academics. They would find out how fragile many of the claims made in expert testimony really are if empirical justifications are desired. On second thought, maybe it is best that they do not find this out because it would raise many questions about expert testimony. The book points up not only the lack of basic research in the clinical fields that could assist legal decision making but also the hope of how the legal system could become more therapeutically oriented.