Court psychiatrist leaves legacy to field

THE BALTIMORE SUN

Had Jonas Rappeport been called to the witness stand, his legions of admirers are fond of saying, John Hinckley Jr. would be sitting in a prison cell today rather than a hospital ward.

The thinking goes that the jurors would have found this slight, owlish-looking psychiatrist irresistible. They would have perceived him as being so commonsensical, so agreeable, so reasonable, that they could do nothing but side with him, rule that Mr. Hinckley was sane when he shot Ronald Reagan and send the would-be presidential assassin to a long, long stay in a penitentiary.

But the prosecution never played the Rappeport card, Mr. Hinckley was found not guilty by reason of insanity, and across the nation there sounded an angry protest to sweep away the insanity defense.

Not testifying in that trial was perhaps the biggest disappointment in a celebrated 40-year career in forensic psychiatry that begins to wind down today when Dr. Rappeport, 67, retires as the chief medical officer of the Baltimore Circuit Court. In that time, he has evaluated tens of thousands of criminal defendants and testified in countless cases in Maryland and across the nation.

Dr. Rappeport's most sweeping contributions undoubtedly occurred outside the courtroom. In the face of the clamor following the Hinckley verdict, he championed the preservation of the insanity defense, calling it a litmus test of society's humanity. More quietly, during the span of his long career, he perhaps more than anyone else yanked his profession -- forensic psychiatry -- from the stature of judicial sideshow to that of accepted medical specialty.

Dr. James Cavanaugh, a colleague at Rush Medical College in Chicago, calls Dr. Rappeport "the father of modern forensic psychiatry."

But last week, in his office in the Clarence Mitchell Courthouse, Dr. Rappeport was recalling the day he didn't get to the witness stand.

As part of the Hinckley prosecution team, Dr. Rappeport spent more than a year preparing for his courtroom appearance. He conducted nearly 20 hours of interviews with Mr. Hinckley. He flew to Colorado to meet with Mr. Hinckley's family. He visited the shop where Mr. Hinckley had purchased the gun and spoke to the Washington policeman who had seen Mr. Hinckley drive by shortly before his assassination attempt.

As the trial neared, he memorized his data, prepared his documentation, rehearsed his testimony and anticipated the cross-examination.

Then, on the eve of his appearance, the phone rang. It was the prosecutor, Roger Adelman. He had decided not to call Dr. Rappeport to the stand.

"He said that he thought we had presented enough psychiatric testimony," Dr. Rappeport recalled. "He thought that the jury was tired, and he didn't want to overwhelm them."

Dr. Rappeport also knew that his assessment of Mr. Hinckley was more equivocal than some of the other members of the psychiatric team. Although he felt Mr. Hinckley knew the difference between right and wrong and was in control of himself -- the twin tests of legal sanity -- he would have testified that Mr. Hinckley "was quite sick with severe personality disorders."

The prosecution may have felt that his testimony would have muddied the waters too much. Those familiar with Dr. Rappeport say that decision may have been a fatal underappreciation of his skills as a witness.

"I don't know what the strategy was in that case," said George Lipman, chief of the Maryland Public Defender's Mental Health Division, "but there's never been a time when I had Jonas on my side that I didn't put him on the stand."

Dr. Rappeport makes no claims about the effect his testimony might have had. "I was terribly depressed about it," he said. "Would I have made the difference? I won't be so grandiose to say that I would have. But I believe I have a way of communicating that is down-to-earth, that is not condescending, that is not haughty. I try to make sense."

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Dr. Rappeport sits at a conference table in his cluttered office surrounded by four psychiatrists who want to follow him into forensic psychiatry. He is a small man with square, large-framed glasses that dominate his oval face and an unexpectedly booming voice to which the others are paying strict attention. But today he is not lecturing, only prodding them with questions.

The topic is a favorite one in forensic psychiatry: should a defendant charged with murder be allowed to go off medication when those drugs are all that would keep him or her competent to stand trial?

It is a fascinating question with several corollaries. What is a doctor's responsibility to a patient? Should a doctor ever knowingly contribute to a patient's suffering? Should a doctor knowingly help a patient avoid prosecution?

Today he allows his students to wrestle with the question for several moments before revealing his hand. "I have a hard time letting this man stop taking his medication just so he can avoid trial," he said.

A quarter century ago when Dr. Rappeport became chief medical officer to the Baltimore courts, discussions like this one would have been rare. Forensic psychiatry was a field without recognized standards or formal training. Psychiatrists often testified, but few bothered to school themselves in the requirements of mental competency or sanity, which are, after all, legal concepts, not medical ones.

"Horrible things would happen," Dr. Rappeport said. "Doctors would come in, express their idiosyncratic feelings with absolutely no backing and someone would end up getting sent to the hospital for life."

Thanks largely to Dr. Rappeport, much of that has changed. In 1969, he organized the American Academy of Psychiatry and the Law, which became a sounding board for issues that serious forensic psychiatrists had grappled with largely in isolation.

The gatherings vastly increased the shared body of knowledge about forensic psychiatry and created standards of evidence. It would no longer be enough to say that a patient was schizophrenic and therefore criminally insane. A psychiatrist would have to be able to prove that the schizophrenia interfered with the patient's ability to control behavior.

The founding of a formal organization also led to the creation of a separate certification examination for forensic psychiatry. That process soon will be subsumed under the American Board of Medical Specialties, meaning that forensic psychiatry will finally become a recognized subspecialty like child psychiatry and geriatric psychiatry.

Soon after becoming Baltimore's chief medical officer in 1967, Dr. Rappeport established one of the first formal training programs in the country. He has since educated virtually every forensic psychiatrist now practicing in Maryland and many beyond.

Aside from his appearance in courtrooms and conferences, Dr. Rappeport largely escaped public notice until the Hinckley verdict and the clamor that followed. The reaction then was not unlike the outrage over the acquittal of the Los Angeles policemen in the beating of Rodney King. The entire nation had watched on television as Mr. Hinckley shot Mr. Reagan, and yet the jury had declared him "not guilty."

Across the nation, politicians, fueled by the public's anger and disbelief, called for the elimination of the insanity defense, insisting that criminals were hiding behind claims of mental illness to avoid punishment. Forensic psychiatry itself came under ferocious attack.

Some states gutted the insanity defense. In the most extreme instances, they adopted a new category: guilty but mentally ill. In those states, defendants are sent to hospitals for the criminally insane. When they are deemed sufficiently recovered, they are then transferred to prison to serve sentences.

"This to me is a false concept," Dr. Rappeport said. "The whole idea of the insanity defense is the fact that we can't hold you culpable because your crime is the result of your mental illness. But then we punish people for that which they can't control."

Through the uproar following the Hinckley verdict, Dr. Rappeport patiently called attention to the facts, chiefly, that the insanity defense is used successfully in a minuscule number of cases. According to a recent study, the insanity plea is raised in only 1 percent of all felony cases and is successfully argued in only a quarter of those.

Dr. Rappeport went to Capitol Hill and accused the politicians of pandering. In Maryland, he served on a gubernatorial task force that was formed to consider strafing the insanity defense. It elected not to do so.

When he got his chance to testify, Dr. Rappeport carried the day. "We have to maintain a level of civility, a level of humanity or we self-destruct," he said.

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