Abstract
This article highlights key aspects of Jonas Rappeport's style (spoken, written, and otherwise manifest) during his long forensic psychiatry career as the founder and first leader of the American Academy of Psychiatry and the Law (AAPL). He was my personal friend in work and play for several decades. A 1989 U.S. Delegation visit to the U.S.S.R. was sponsored by the U.S. Department of State, the American Psychiatric Association (APA), and the National Institutes of Mental Health (NIMH) to investigate the abuse of psychiatry. Jonas was one of three forensic psychiatrists chosen to be key examiners of hospitalized and released U.S.S.R. dissidents whose psychiatric evaluations and subsequent forensic consequences were evaluated. The longtime unwarranted detention and treatment of these dissidents in special psychiatric/prison hospitals was a clear manifestation of the abuse of psychiatry. Each psychiatric examiner team included a NIMH research psychiatrist, a forensic psychiatrist, and a native Russian speaking psychiatrist who previously had emigrated to the United States. I describe the purpose, procedures, work, and results of the 1989 Delegation visit to the U.S.S.R. and selected aspects of Jonas's and other forensic examiners' findings about the behavior and thinking of Soviet psychiatry's organizational leaders regarding criminal responsibility.
Several of Jonas Rappeport's major contributions to forensic psychiatry and AAPL are very nicely summarized in this Festschrift by the excellent article by Janofsky and Tellefsen.1 As was so for many others, Jonas and his wife Joan were my personal friends for several decades.
In reviewing Jonas's life, I first noted that the founding meeting of the forensic psychiatry program directors was in 1969, at a Miami American Psychiatric Association (APA) meeting. That same year is also highly relevant to a subject widely current and discussed in American thought and culture. It was at that very same time, the 1969 APA Miami meeting, that Chester Pierce, MD, my nationally revered Massachusetts General Hospital psychiatry residency supervisor, led the Black Psychiatrists of America to protest racial injustice and exclusion by the then APA Board of Directors. Jonas Rappeport, just like Chester Pierce, was an engaged professional activist throughout his long career. 1969 was a memorable year for so many.
Early Professional History
I first saw Jonas very much in action at early APPL meetings in the 1970s. Jonas met with my wife Ellen and me even before the meeting began. He was near the hotel steps and personally greeted most attendees. This APPL meeting was superb, and I was hooked. I became one of the early written compilers and greeters for new AAPL members, encouraging them to bring other colleagues to our organization.
Shortly thereafter (1976), I organized the first AAPL Newsletter, then not printed, but with text distributed. My wife Ellen became the Newsletter cartoonist for “Dr. For and Sic's” adventures. There is, I should also note, no comparison here between early AAPL Newsletters versus the present versions of the wonderfully informative and interesting newsletters. Prior to my personally meeting Jonas, when I was working at the NIMH with Dr. Saleem Shah (1972–1974), I had learned about Jonas's early initiation of the Baltimore Forensic Fellows NIMH supported program.
This is not the best format for my making extensive commentary about Jonas's many written articles on forensic psychiatry. To be brief, they are interesting, clear, fun to read, and basic to forensic psychiatry and its significant concerns and practices. These articles include, among many others, “Differences Between Forensic and General Psychiatry”,2 “Effective Court Room Testimony”,3 “A Functional Retrieval System for Forensic Psychiatrists”,4 “Defendants Pleading Insanity: An Analysis of Outcomes”,5 “The Insanity Defense and Mental Illness”,6 “The Present and Future of Forensic Psychiatry”,7 and “Reasonable Medical Certainty”.8
Jonas's written style and personal assertiveness come through clearly. For example, I especially noted his opening comments in the article “Reasonable Medical Certainty”: “I have discovered that the status of reasonable medical certainty is quite uncertain. In fact, I can make the statement that I am certain that reasonable medical certainty is quite uncertain” (Ref. 8, p 5).
Personal Life
On the personal level, my fondest memories of Jonas and Joan relate to our joint bluefish adventures on Chesapeake Bay. My then 12-year-old son Jonathan and I were treated to Jonas “in action.” Jonas's plan for the day pushed all of us relentlessly. First, we drove about 200 miles to the mouth of the Potomac River where we were indulged by sitting at a farm table overlooking the water, each personally pounding large mallets to open the distinct shells of Maryland Blue Crabs (an infinite number of them). We prepared for a four-hour sleep prior to awakening at 4 am. We then watched Jonas grind multiple whole large fish for bait, also stocking the boat. That bright sunny day we caught more than 120 bluefish, cleaning and preparing them on the dock. Coming into the harbor Jonas spotted many birds flocking and a small change in the air near to the dock. This was a billowing fish frenzy where upon even casting a bare hook brought forth a still fighting bluefish, in less than ten seconds.
Jonas was masterful in every aspect of this fun trip. He met every challenge, this reminiscent of a remark I read personally characterizing him and his choices. He noted, “Actually, I happen to be very mechanically oriented … ” (Ref. 9, p 40). This is an understatement.
Jonas was a very direct speaker and author. He was often quite spontaneous about his self-views and beliefs, while at the same time having clear plans and intentions to achieve his desired outcomes. One always knew what Jonas was thinking.
1989 Delegation to the U.S.S.R.
In the remainder of this brief article, I will discuss the 1989 U.S. (APA/NIMH/U.S. Department of State) 1989 Delegation to the U.S.S.R. to assess recent changes in Soviet psychiatry wherein Jonas played an essential role. This unique 1989 Delegation visit was undertaken at an extraordinary time in U.S.S.R.–U.S. diplomatic relations. It was a part of the Helsinki process aimed at evaluating the state of human rights in the Soviet Union and whether the U.S.S.R. continued to use psychiatry to oppress dissents. In particular, the visit was also to decide whether the APA should renew its relationship with the All-Union Society of Psychiatrists and Narcologists and whether (over time) they should be readmitted to the World Psychiatric Association. The Soviet psychiatrists were forced to leave the WPA in 1983 because of the numerous allegations of Soviet abuse of psychiatry for political purposes.
There were three more specific objectives of the 1989 visit:
To ensure that the past victims of coercive and unwarranted psychiatric hospitalization in the U.S.S.R. were released (the State Department's primary rationale).
To document the occurrence of psychiatric abuse of human rights, if any (a central APA objective). Because of the continued public denials of psychiatric abuse by leading U.S.S.R. governmental psychiatrists, there was not yet evidentiary proof that Soviet psychiatric abuse had occurred. Our delegation expected to find “proof” that what had been “alleged” about Soviet psychiatric abuse had occurred.
To nurture international collaboration among psychiatrists and thereby promote a worldwide profession of psychiatry committed to a uniform diagnostic approach and common ethical principles (a common aim of NIMH and the APA). These goals had been undermined and “abused” by U.S.S.R. psychiatrists. It was hoped that this mission could promote both future international collaboration as well as better psychiatric care for all U.S.S.R. patients.
These three 1989 visit objectives were accomplished, although the third objective was only partially met at best.
To do our work, the 1989 Delegation examined 27 alleged victims of psychiatric abuse, including 15 hospitalized and 12 released persons. “17 [additional patients] were discharged either before or during the Delegations visit” (Ref. 10, p 2).
Among the 15 still hospitalized patients there remained “five individuals (including one patient still undergoing forensic evaluation) for whom the U.S. team did not believe a mental disorder diagnosis was warranted according to U.S. (DMS-III–R) or international (ICD-10 draft) criteria. Two of these patients remained hospitalized under Article 70, one of the ‘political articles’ of the Soviet Criminal Codes involving Anti-Soviet Agitation and Propaganda” (Ref. 10, p 2).
U.S.S.R. RSFSR Criminal Code, General Part, Chapter 3: Crime, political Article 70 describes this criminal offense: “Agitation or propaganda carried on for the purpose of subverting or weakening the Soviet regime (vlast') or committing, especially dangerous crimes against the State, or the circulation, for the same purpose of slanderous fabrications which defame the Soviet state and social system…” (Ref. 10, p 74). A similar but less serious criminal offense is described in political article 190-1: “Circulation of Fabrications Known to be False Which Defame Soviet State and Social System” (Ref. 10, p 74).
“Among the 12 released patients the U.S. Team found no evidence of any past or current mental disorder in 9, and the remaining 3 had relatively mild symptoms that would not typically warrant involuntary hospitalization in Western countries” (Ref. 10, p 2).
Professional examinations of these patients included lengthy interviews (often five hours), including administration of the Structured Clinical Interview for DSM-III–R, Psychotic Disorders (SCD-PD)11 that focused more on very serious disorders (e.g., schizophrenia, the usual Soviet dissident diagnosis), and the International Personality Disorders Examination.12
In addition to extensive history taking and mental status examination, the U.S. team constructed a specially devised Forensic Interview Schedule protocol for each person. This protocol included precipitating behaviors for a person's arrest and involuntary hospitalization, detention, and commitment process, observance of the person's legal rights (as noted in Soviet law), conditions of hospitalizations, and treatment (Ref. 10, p 65). The patient interviews also included categories of process and conditions of release and community adjustment and social dangerousness. The latter provided an opportunity to fill in any gaps or to obtain additional relevant information about the patient's history of dangerous behavior (Ref. 10, p 65). Where possible, family members were questioned to corroborate these events.
For these patients, this initial hospitalization was practically always in special psychiatric hospitals. These hospitals were not run by the Soviet Ministry of Health but by the Ministry of the Interior (prison psychiatric hospitals). These hospitals were notorious regarding their primitive treatment conditions, which were clearly at times punitive (e.g., use of Sulfazine, a physically painful nontherapeutic sulfur injection “treatment”). Prior to the Delegation's visit, no Westerners had been permitted to visit these special hospitals. The Delegation's hospital visit team confirmed the dismal conditions of these hospitals (Ref. 10, pp 39–43).
The composition of the Delegation's three patient interviewing teams was truly unique. Each included a NIMH research psychiatrist diagnostic expert and a clinical psychiatrist who was a previously trained Russian-speaking U.S.S.R. citizen who had emigrated to the United States. This approach compensated for cultural differences between the two countries. Each team also included a well-known U.S. forensic psychiatrist or psychologist. These team members were chosen by the U.S. delegation.
All interviews were conducted in Russian either by the clinical psychiatrist trained in Russia or with the assistance of interpreters (two for each team). Thus, there were simultaneous bilateral conversations in both Russian and English for all patient interviews.
Each of the above considerations was agreed upon by protocol accepted by both the United States and Soviet Union. The U.S. team wanted not only to ensure the validity of our conclusions but also to ensure against any conditions that might frighten or intimidate these consenting persons during our interviews with them or their relatives. We had to guard against Soviet manipulation of the examined persons' mental states. This had been a likely problem in previous attempts by the United States and other countries to document Soviet psychiatry abuse. An example of the above approach is that we examined the released persons, who never again wanted to be hospitalized, in a Soviet hotel rather than in any other Soviet settings. To our amazement the persons we examined were not reluctant or intimidated. They were instead very pleased for this opportunity. Previously these persons had never imagined they would be carefully examined by American psychiatrists. For them, this was their “day in court.” The same was true for the relatives or friends with whom we talked.
A revised agreement was negotiated in Moscow only shortly before the Delegation arrival, which allowed the Soviet psychiatrists the opportunity to be present and silently view the U.S. team interviews, then for themselves to interview the U.S.S.R. patients without U.S. interruption and to discuss each of the interviews and patients with the U.S. team. Fairness dictated this approach for meaningful patient-related dialogue between the U.S. and Soviet psychiatrists. As noted above, however, the U.S. team could not permit the Soviet psychiatrists to intimidate the patients prior to their examinations by the U.S. teams. During these final last-minute negotiations, I (as the U.S. psychiatric team leader) rejected the lead Soviet psychiatrist's demand that they first interview the patient or that both the U.S. and Soviet psychiatrists together jointly interview the patients. This very tough negotiation nearly caused the Delegation visit to be cancelled altogether. Jonas Rappeport was one of the three forensic interviewers. Jonas's group included Sam Keith, MD (NIMH) and Vladimir Levit (a practicing clinical psychiatrist and U.S. emigree). As the psychiatric leader of the 1989 Delegation, I chose Jonas to participate because of his excellence, long relevant forensic experience, enthusiasm for the assignment, and interview style, which produced a thorough practical approach leading to the best understanding.
Jonas was an outstanding contributor to this mission, including both the forensic and clinical interviews. It was obvious that Jonas truly enjoyed himself, though working very long hours under difficult conditions. He and the other participants (26 diverse U.S. experts, including physicians, attorneys, civil rights specialists, and State Department officials) found this to be a unique, fascinating, and exhausting experience. This trip to the U.S.S.R. lasted more than three weeks for some of us. Each of the forensic mental health professionals (Jonas, Joe Bloom, and John Monahan) contributed their forensic findings for inclusion in the findings, analysis, and final report.
Jonas's comments, as well as those made by the other forensic professionals, were of great value. Only one patient had attended his own trial (Ref. 10, p 5). They were tried in absentia, though some patients did have family members present. As noted in the Delegation's final report, “[w]ith the exception of one case, they never met with a defense attorney …” (Ref. 10, p 5). Defense attorneys were appointed in some cases and attended trials. But they were ineffective or did not contest the finding of the prosecutors. “Of those interviewed on these points, only three patients reported seeing the investigative report; none reported being presented with the experts' findings …” (Ref. 10, p 5).
Of forensic interest within Soviet criminal law13 was the subject of nonimputability. Article 11 of the R.S.F.S.R. Criminal Code specifies the Soviet approach to nonimputability. “A person shall not be subject to criminal responsibility who at the time of committing a socially dangerous act is in a state of nonimputability; that is, cannot realize the significance of his actions or control them because of a chronic mental illness, temporary mental derangement, mental deficiency or other condition of illness. Compulsory measures of a medical character may be applied to such a person by order of the court” (Ref. 10, p 35, citing Ref. 13, p 128).
A finding of nonimputability is required for hospitalization versus criminal incarceration. It is therefore of forensic interest how such conclusions were reached by the Soviet forensic psychiatrists. Here the comments of both Jonas Rappeport and Joe Bloom (taken from their reports to me) are of great interest.
As noted by Jonas Rappeport, “It was my impression that the criminal charge (Article 70 or 190-1) together with the schizophrenia diagnosis and the ‘danger to the Soviet Union’ was considered sufficient to warrant a finding of nonimputability.”
Joe Bloom's summary forensic report builds upon this theme: for the Soviet forensic psychiatrists, diagnosis is everything:
They seem to operate in an atmosphere in which environmental events, what may have actually happened in the patient's life, were off limits to them and diagnosis became all important. They also showed no evidence of dealing with such typical forensic psychiatric issues as the specific legal test for imputability or whether the patient continued to be dangerous at the time of their periodic reevaluations while in the special hospitals.
The retained reports of Jonas Rappeport, Joe Bloom, and John Monahan are available from the author.
Additional diverse information from all examining teams regarding nonimputability is presented in the U.S. team's final Executive Summary (Ref. 10, p 3):
The concept of a "nonimputable" mental disorder in the Soviet system has been used to encompass at least three different symptom levels found in these patients, as follows:
Psychotic symptoms associated with the commission of a violent or illegal act, in which the patient's impaired understanding or volitional control was directly related to his or her criminal behavior;
Any current or past diagnosed mental disorder or psychiatric symptom in a person accused of having committed illegal behavior (even in the absence of any apparent impairment of the patient's understanding of, or capacity to control, his or her behavior);
Anti-Soviet political behavior, including writing books, demonstrating for reform, or being outspoken in opposition to the authorities, which was defined in some patients as being simultaneously a symptom (e.g., "delusion of reformism"), a diagnosis (e.g., "sluggish schizophrenia"), and a criminal act (e.g., violation of Articles 70 or 190-1).”
A final note of interest is that the Soviet Ministry of Health (and, as we now know, the KGB14) set numerous obstacles before the U.S. Delegation. These were eventually overruled by the Soviet Foreign Ministry, itself wanting this visit to occur for diplomatic reasons. Nevertheless, critical patient records were either not available, not copied as had been agreed upon, not produced in a timely fashion, or denied altogether. The Delegation had no working access to police records and other key documents. All deficiencies along the way had to be further arbitrated by the U.S. State Department and Soviet foreign ministry, successfully or not. Without this approach there would have been no Delegation visit possible at all.
Conclusion
In summary, Jonas Rappeport, our first AAPL leader and creator, was a practical, outcome-directed person. He did what he promised to do. He loved forensic psychiatry and AAPL. His life was a blessing for the evolution and growth of AAPL and forensic psychiatry generally.
Jonas Rappeport's intellectual life paralleled his approach to bluefishing trips: Have fun, get it done the right way, take due pride in your passion and accomplishments.
For me, Jonas is a man who achieved his key aims during a very long and interesting life.
We surely miss him.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2021 American Academy of Psychiatry and the Law