Analysis of NYAPRS Opposition to Kendra’s Law

Presented by DJ Jaffe
NYC Mental Health Committee Hearing.
Mental Illness Policy Org. 50 East 129 St. NY NY 10035

Important Addendum (6/2012): In recent letters to the editor, Mr Rosenthal of NYAPRS (a trade association for providers of non-medical services to voluntary patients) claims that raising Medicaid rates for their members and and expanding voluntary services is a substitute for Kendra’s Law. It is not. Kendra’s Law is only for those who refuse treatment. Raising Medicaid rates and increasing voluntary services will not change a patients ability to refuse services.

Following is a chart that contrasts the testimony of the New York Association of Psychiatric Rehabilitation Services ( NYAPRS, a trade association a trade association of providers of non-medical services to mental health consumers who are willing to voluntarily accept services) The testimony was presented in New York City at the Public Hearing on Kendra’s Law in NYC co-chaired by Assembly members Rivera and Lentol. The New York Lawyers in the Public Interested and NY Civil Liberties Union also presented similar testimony.

Mr. Rosenthal’s Claim

Research Findings


“In closing, there is simply no proof to make Kendra’s Law permanent“ • 74% fewer participants experienced homelessness
• 77% fewer experienced psychiatric hospitalization
• 83% fewer experienced arrest
• 87% fewer experienced incarceration.
• Individuals in Kendra’s Law were also more likely to regularly participate in services and take prescribed medication.
• On average, AOT recipients’ length of hospitalization was reduced 56% from pre-AOT levels.
• 55% fewer recipients engaged in suicide attempts or physical harm to self
• 49% fewer abused alcohol
• 48% fewer abused drugs
• The number of individuals exhibiting good adherence to medication increased by 51%.
• The number of individuals exhibiting good service engagement increased by 103%.
March 2005 “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.” N.Y. State Office of Mental Health
“There is no proof that people with severe psychiatric disabilities are more violent” • People with mental illness are not more violent than others.
• People with serious mental illness are not more violent than others.
• People with serious mental illness who are not in treatment are more violent as a group than others.
Fact sheet attached.
 “(There is), no proof to therefore to suggest that this initiative is an effective public safety measure” • 47% fewer physically harmed others,
• 46% fewer damaged or destroyed property
• 43% fewer threatened physical harm to others.
• Overall, the average decrease in harmful behaviors was 44%.
March 2005 “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.”
• Patients given mandatory outpatient treatment – who were more violent to begin with – were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. February 2010 Columbia University. “Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State” Phelan, Sinkewicz, etc. Psychiatric Services, Vol 61. No 2
“(There is) no proof that court orders, rather than more responsive, more accountable, better coordinated and funded services, have created the improved outcomes” • The likelihood of a hospital admission over six months was  “highly statistically significant” and lower among AOT recipients than among voluntary recipients.
• AOT patients were less likely to be arrested than their voluntary counterparts
• Persons receiving AOT for 12 months or more had a substantially higher level of personal engagement in treatment than those receiving services voluntarily.
June 2009 Duke University  “New York State Assisted Outpatient Treatment Program Evaluation.” Swartz, Swanson, Steadman, Robbins, and Monahan.
“In fact, the only incontrovertible truth we can agree on is which group has been the greatest target of court mandated care and that is people of color and that is dead wrong.” • We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.
• Parallel analyses for Hispanics and other minority populations show this same pattern and no appreciable racial disparities are evident in selection of these groups for AOT.
June 2009 Duke University
“AOT …creates an atmosphere of distrust between the consumer and the provider. *It sets the providers against the very people they serve” • Improved Access to Services. AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.
• Improved Treatment Plan Development, Discharge Planning, and Coordination of Service Planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.
• Improved Collaboration between Mental Health and Court Systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.
• There is now an organized process to prioritize and monitor individuals with the greatest need;
• AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve;
• Increased collaboration between inpatient and community-based mental health providers.
March 2005  “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.”
“Over the past decade, the debate over the justness and the actual impact of the use of court-ordered outpatient mental health treatment has emerged as one of the most contentious controversies in our mental health system.” There is little albeit vocal, opposition to Kendra’s Law
•  Democrats and Republicans both overwhelmingly supported enactment of Kendra’s Law(Senate 49-2, Assembly 142-4).
• Liberal (NY Times, Newsday) and conservative (Post, Daily News) media supported enactment of Kendra’s Law.
• Mental Illness advocates (NAMI, GNYHA, APA); Public Safety Advocates (NYSCOP, DAASNY); and Health care workers (PEF, APA, Psychiatric Nurses) support Kendra’s Law
Source: Various
 • “At present, 42 states have laws mandating outpatient care for individuals with severe mental illnesses. ***“
• “Outpatient commitment for people with mental illnesses (has) been heralded as necessary and effective by some, and as overly coercive and counterproductive by others — but our study has found few of the negative consequences feared by critics of Kendra’s Law. The real take home message of the research, as Dr. Link sees it, is that a policy that provides enhanced treatment for people with serious mental illnesses can improve their life circumstances and reduce the risk of violence.
February 2010, Columbia University
“Involuntary outpatient commitment (is) based on false premise (that)… People with psychiatric disabilities are frequently so sick that they can’t understand their need for care, leading to avoidance and noncompliance” Impaired awareness of illness (anosognosia) is caused by damage to specific parts of the brain, especially the right hemisphere.  It affects approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar disorder.  When taking medications, awareness of illness improves. • “ Lack of Insight in Psychotic and Affective Disorders: A Review of Empirical Studies.” Harvard Review of Psychiatry, May/June: 22-33, 1994.
• Archives of General Psychiatry 1994 (51): 826-836 Amador
“Forced treatment unjustly violates people’s rights.” “(I)t is now well settled that Kendra’s Law is in all respects a constitutional exercise of the states police power, and its parens patriae power. Further, the removal provisions of the law have withstood constitutional scrutiny. (Note that Kendra’s Law does not allow ‘forced’ treatment. That can only be done under the criteria established by Rivers v. Katz.) June 2009 Duke University (appendix)
““Forced treatment …erodes their faith in the service system.” • 87% of participants interviewed said they were confident in their case manager’s ability to help them
• 88% said they and their case manager agreed on what is important for them to work on.
• 75% reported that AOT helped them gain control over their lives,
• 81% said AOT helped them get and stay well
• 90% said AOT made them more likely to keep appointments and take medication.
March 2005 “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.”
(P)eople who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem. February 2010, Columbia University