Kendra's Law, effective since November 1999, is a New York State law concerning involuntary outpatient commitment. It grants judges the authority to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours. Kendra's Law does not require that patients are forced to take medication.
Contents
- Background
- Criteria
- Support
- National
- Statewide
- Regionallocal
- Selected individual supporters
- Founding supporters
- Opposition
- Studies
- Current status
- References
It was originally proposed by members of the National Alliance on Mental Illness, the Alliance on Mental Illness of New York State, and many local NAMI chapters throughout the state. They were concerned that laws were preventing individuals with serious mental illness from receiving care until after they became "dangerous to self or others". They felt the law should work to prevent violence, not require it. They viewed outpatient commitment as a less expensive, less restrictive and more humane alternative to inpatient commitment.
The members of NAMI, working with NYS Assemblywoman Elizabeth Connelly, NYC Department of Mental Health Commissioner, Dr. Luis Marcos, and Dr. Howard Telson were successful in getting a pilot outpatient commitment program started at Bellevue Hospital.
Background
In 1999, there was a series of incidents involving individuals with untreated mental illness becoming violent. In two similar assaults in the New York City Subway, a man diagnosed with schizophrenia pushed a person into the path of an oncoming train. Andrew Goldstein, then 29, while off medication, pushed Kendra Webdale to her death in front of an oncoming N train at the 23rd Street station. The law is named after her. Her family played a significant role in getting it passed. Subsequently Julio Perez, age 43, pushed Edgar Rivera in front of an uptown 6 train at 51st Street. Rivera lost his legs and became a strong supporter of the law. Both Goldstein and Perez had been discharged by psychiatric facilities with little or no medication. Kendra's Law, introduced by Governor George E. Pataki, was created as a response to these incidents. In 2005, the law was extended for 5 years.
As a result of these incidents, involuntary outpatient commitment moved from being a program to help the mentally ill to a program that could increase public safety. Public safety advocates joined advocates for the mentally ill in trying to take the successful Bellevue Pilot Program statewide. What was formerly known as involuntary outpatient commitment was re-christened as assisted outpatient treatment, in an attempt to communicate the positive intent of the law.
Criteria
Kendra's Law basically allows courts to order certain seriously mentally ill individuals to accept treatment as a condition for living in the community. The law is aimed at a small group who have a history of rehospitalization that is associated with going off medications.
In order to be admitted to Kendra's Law, individuals must meet the following criteria established in Section 9.60 of NYS Mental Health Law. A patient may be ordered to obtain assisted outpatient treatment if the court finds that:
- at least twice within the last thirty-six months been a significant factor in necessitating hospitalization in a hospital, or receipt of services in a forensic or other mental health unit of a correctional facility or a local correctional facility, not including any period during which the person was hospitalized or incarcerated immediately preceding the filing of the petition or;
- resulted in one or more acts of serious violent behavior toward self or others or threats of, or attempts at, serious physical harm to self or others within the last forty-eight months, not including any period in which the person was hospitalized or incarcerated immediately preceding the filing of the petition; and
Support
According to the Treatment Advocacy Center (treatmentadvocacycenter.org), the following organizations (in part or in full) support the law:
National
Statewide
Regional/local
Selected individual supporters
Founding supporters
Opposition
Kendra's Law is opposed for different reasons by many groups, most notably the Anti-Psychiatry movement and the New York Civil Liberties Union. Opponents say that the law has harmed the mental health system, because it can scare patients away from seeking treatment. The implementation of the law is also criticized as being racially and socioeconomically biased.
Tom Burns, the psychiatrist who originally advised the United Kingdom's government on United Kingdom's Laws that are similar to Kendra's Law, has also come to the conclusion they are ineffective and unnecessary. Professor Burns, once a strong supporter of the new powers, said he has been forced to change his mind after a study he conducted proved the orders "don't work".
John M. Grohol, PsyD, in his article "The Double Standard of Forced Treatment", says "Forced treatment for people with mental illness has had a long and abusive history, both here in the United States and throughout the world. No other medical specialty has the rights psychiatry and psychology do to take away a person’s freedom in order to help “treat” that person. Historically, the profession has suffered from abusing this right — so much so that reform laws in the 1970s and 1980s took the profession’s right away from them to confine people against their will. Such forced treatment now requires a judge’s signature. But over time, that judicial oversight — which is supposed to be the check in our checks-and-balance system — has largely become a rubber stamp to whatever the doctor thinks is best. The patient’s voice once again threatens to become silenced, now under the guise of “assisted outpatient treatment” (just a modern, different term for forced treatment)."
The New Mexico Court of Appeals declared an Albuquerque ordinance, modeled after Kendra's Law, requiring treatment for some mentally ill people conflicts with state law and can't be enforced.
Studies
A 2014 Cochrane systematic review of the literature found that compulsory community treatment "results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care."
A Cochrane review of two relevant trials, and a subsequent randomized, controlled trial, both published in the peer-reviewed literature, found no measurable benefits to compulsory treatment. Two studies for the New York State Department of Mental Health, not published in the peer-reviewed literature, found benefits, but could not tell how much of it was the result of the compulsory aspect of the program and how much was the result of the additional services provided.
A review article published by The Cochrane Library found no evidence that compulsory community treatment was an effective alternative to standard care. The only two relevant trials found "little evidence of efficacy on any outcomes such as health service use, social functioning, mental state, quality of life or satisfaction with care."
We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review.
A randomized, controlled trial published in The Lancet concluded, "the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty."
Of 442 patients assessed, 336 patients were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients). One patient withdrew directly after randomisation and two were ineligible, giving a total sample of 333 patients (166 in the CTO group and 167 in the Section 17 group). At 12 months, despite the fact that the length of initial compulsory outpatient treatment differed significantly between the two groups (median 183 days CTO group vs 8 days Section 17 group, p<0·001) the number of patients readmitted did not differ between groups (59 [36%] of 166 patients in the CTO group vs 60 [36%] of 167 patients in the Section 17 group; adjusted relative risk 1·0 [95% CI 0·75—1·33]).
A 2005 study, Kendra's Law A Final Report on the Status of Assisted Outpatient Treatment done by New York State's Office of Mental Health, concluded, "Over a three year period prior to their AOT order, almost all (97%) had been hospitalized (with an average of three hospitalizations per recipient), and many experienced homelessness, arrest, and incarceration. During participation in the AOT program, rates for hospitalizations, homelessness, arrests, and incarcerations have declined significantly, and program participants have experienced a lessening of the stress associated with these events."
A 2009 study, New York State Assisted Outpatient Treatment Evaluation done by Duke University, Policy Research Associates, University of Virginia, concluded that New York State's program
improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients. The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes. It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.
The authors said that the evaluation reflected not just the compulsory aspects of the program, but the additional resources provided for recipients, particularly in New York City.
Current status
On January 15, 2013, New York Governor Andrew Cuomo signed into law a new measure that extends Kendra's Law through 2017.