Top Mental Health Groups Seek Extension Not Permanence for Kendra's Law

ALBANY, NY (06/01/2010)(readMedia)-- A coalition of leading NYS mental health organizations representing the broad array of key stakeholders all agree that a five year extension of Kendra's Law, as recommended by the NYS Office of Health and introduced by the both Legislative Mental Health Committee Chairmen in A.10790 (Ortiz), S.7254 (Morahan), is the most appropriate course to allow for the implementation of a variety of strategies to address numerous questions left unanswered by a legislative mandated study.

"An extension of five years will enable the Legislature and the Executive to examine and address the law's unequal geographic implementation, and its disproportionate impact upon people of color, as well as to monitor a very promising new package of strategies aimed at enhancing the responsiveness and effectiveness of voluntarily provided services to similar groups of individuals covered by Kendra's Law."

"Whenever the State invokes its police power to restrict freedoms, it must be done only after great deliberation and with the knowledge that the restriction of one's personal liberty yields only the best possible outcomes for individuals and for the community." Excerpts from the groups' bill memos (see below for more details)

Identical bills to extend Kendra's Law for an additional five years have been backed by the chairs of both houses Mental Health Committees (A.10790 Ortiz, S.7254 Morahan) and were approved by those committees over the past two weeks and are poised for passage by both houses. Many groups have issued and/or signed on to memos of opposition to proposals aimed at expanding Kendra's Law and making it permanent (A10421 Gunther/S7596 Young). Most recently, the Poughkeepsie Journal editorialized in favor of the extender (see below).

BACKGROUND

Troubled by dramatic differences in the use of court ordered and voluntary care under Kendra's Law between downstate and upstate counties and the disproportionate number of New Yorkers from communities of color who were receiving court ordered mental health care, the NYS Legislature extended Kendra's Law in 2005 for an additional five years and ordered independent research to look into these and other disparities in the law's implementation. The result?

The 2009 Study Found Marked Geographic Disparities

in the Use of Voluntary vs. Court Ordered Approaches

The Duke evaluation confirmed there were great geographic disparities in the implementation of Kendra's Law, with 82% (8,275) of the orders emanating from New York City and Long Island. The study found that "…in other counties, largely outside of New York City, voluntary agreements are more frequently used before a…court order." In fact, most other counties offered almost 7,000 individuals a variety of voluntary service packages, with 24 upstate counties using 5 or less orders in total since the program's inception in November of 1999. The study quoted a psychiatrist from an upstate county: "We don't do it like downstate…We use the voluntary order first. We don't approach it in an adversarial way."

Yet the Study Failed to Compare Voluntary and Court Ordered Care

Despite the high ratio of voluntary and involuntary care approaches to at risk individuals in New York statewide, the study only provided research into 6 counties. Using such a small sample, the study concluded that "available data allow only a limited assessment of whether voluntary agreements are effective alternatives to initiating or continuing (court ordered care)."

Further, the 2009 Research Continued to Find High Racial Disparities

The Duke evaluation further found no change in the overrepresentation of African Americans and Hispanic New Yorkers in the group receiving court ordered care. Just as in the 2005 study, 64 percent of involuntary orders were levied at those groups with one notable difference: court orders for Hispanic New Yorkers jumped up by almost half (from 21% to 31%).

This striking imbalance continues to turn up even in areas of the state where those groups are vastly outnumbered. Examples include Rockland where African Americans and Hispanics receive 78% of the orders while they comprise only 20% of the population and Westchester where they get 50% of the orders as they comprise 29% of the population.

These findings continue to point to an unchecked systemic deficiency in providing effective outreach and engagement services to communities of color with psychiatric disabilities that remains unaddressed, even though these disparities were highlighted five years ago. Can't we improve access to mental health services for communities of color without using coercive court mandates?

The Proposed 5 Year Extender Will Ensure Emphasis on New Initiatives

In proposing another five year extension of Kendra's Law, the NYS Office of Mental Health is seeking to examine the impact of several new initiatives aimed at improving voluntary mental health outreach and engagement services to underserved groups, including African American and Hispanic New Yorkers with serious mental illnesses.

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Excerpts from Memos from New York State's Leading Mental Health Advocates

"An extension of five years as the NYS Office of Mental Health requests will enable the Legislature and the Executive to examine and address Kendra's Law's unequal geographic implementation, and its disproportionate impact upon people of color. Further, it will afford regulators and lawmakers the opportunity to monitor the efficacy of new and expanded community based voluntary services including the NYC Mental Health Care Monitoring Teams, Pathways to Housing, Outpatient Clinic Restructuring, New York/.New York III Housing, Chronic Illness Demonstration programs, and improved mental health coverage through public and private health insurance."

Shelly Nortz, Coalition for the Homeless snortz@cfthomeless.org

"Culturally-centered innovative strategies for outreach and engagement must be first used when addressing the needs of Hispanics and other underserved communities."

Dr. Rosa Gil, Founder, President & CEO of Comunilife, Inc

"We support a five year extension of the law because it will provide the Legislature and The Executive with an opportunity to examine and review some of the alternative service enhancement models and help determine if these models will provide the integrated services and supports that are needed to help individuals recover and move forward with their lives."

Glenn Liebman, Mental Health Association NYS gliebman@mhanys.org

"Whenever the State invokes its police power to restrict freedoms, it must be done only after great deliberation and with the knowledge that the restriction of one's personal liberty yields only the best possible outcomes for individuals and for the community. NYSRA believes sufficient questions remain about this statute's disparate impacts from one community to the next and toward racial minorities, and thus urges enactment of an extension rather than a removal of the Kendra's Law sunset date."

Jeffrey Wise New York State Rehabilitation Association jeff@nyrehab.org

"When it was enacted, Kendra's Law was an untested approach to mental health care using court-ordered, out-patient treatment for certain individuals. More must be done to ensure that people are receiving the care they need, fairly and in the most appropriate setting. Extending the law will allow government, the mental health system and advocates additional time to develop additional options for providing the best treatment possible."

Karen Schimke Schuyler Center for Analysis and Advocacy kschimke@scaany.org

"We believe that by extending the current law and allowing counties to continue to explore alternatives, giving us time to see how clinic restructuring and federal health reform are going to impact it and giving us some time to see how our economy will effect the availability of services to the public mental health system in its entirety in the future, the legislature would be in a much better position to make a decision about whether this law should be made permanent and whether any changes are necessary to make it more effective."

NYS Conference of Local Mental Hygiene Directors kh@clmhd.org

"The (study's) results beg the question: is this population's non-compliance with outpatient treatment a symptom of their illness or do individuals lack appropriate access to and assistance coordinating necessary services absent a court order." Greater New York Hospital Association aburke@gnyha.org

"The researchers also found great geographic disparities in the implementation of Kendra's Law, with 82% of the orders emanating from New York City and Long Island: "...in other counties, largely outside of New York City, voluntary agreements are more frequently used before an AOT court order." In fact, 24 upstate counties used 5 or less orders in total since the program's inception in November of 1999.

The Duke evaluation further found no change in the overrepresentation of African Americans and Hispanic New Yorkers in the group receiving court ordered care, a striking imbalance that continues to turn up even in areas of the state where those groups are vastly outnumbered.

These findings continue to point to an unchecked systemic deficiency in providing effective outreach and engagement services to communities of color with psychiatric disabilities that remains unaddressed, even though these disparities were highlighted five years ago.

Harvey Rosenthal, New York Association of Psychiatric Rehabilitation Services

"By extending Kendra's law and not making it permanent, New York State will have an opportunity to examine the usefulness of court-ordered participation in relation to voluntary types of programs. Researchers are inconclusive on the long term effects of Kendra's Law and the benefits of court-ordered versus voluntary participation. (The Duke study)… did not prove that court-ordered participation was more efficacious then voluntary approaches.

Phillip Saperia Coalition of Behavioral Health Agencies psaperia@coalitionny.org

"While we feel Kendra's Law can be improved to better serve patients and the community, we believe extending the existing law is the proper course of action to assure appropriate outpatient services are available for patients served by the Kendra's Law. Doing so will allow for continued assessment of the law and recommendations to the Legislature that are commensurate with evolving research." Barry B. Perlman, M.D., Chair of the Committee on Legislation and the Immediate Past-President, New York State Psychiatric Association richardgallo@galloassociates.org

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KENDRA'S LAW FACT SHEET

1. In contrast to public statements that A.10790/S.7254, the bill introduced by both legislative Mental Health Committee chairs Assemblyman Felix Ortiz and Senator Thomas Morahan, threatens to dismantle Kendra's Law, it does not jeopardize the program; rather, it extends the law for a full five years.

In 2005, an extender was proposed by the NYS legislature; in 2010, the extender is being proposed by the Administration and the Office of Mental Health, which is seeking to evaluate the impact of a recently launched package of voluntary alternative strategies to engage at risk individuals, especially in the New York City area, where over 70% of the orders originate.

2. A broad majority of the state's most prominent mental health advocacy groups back the chairmen's extender bill and are opposed to S.S7596 (Young)/A.10421(Gunther) that would make the program permanent and expand its reach.

Currently, those groups include Association for Community Living, Center for Disability Rights, Coalition for the Homeless, Coalition of Behavioral Health Agencies, Families Together of New York State, Geriatric Mental Health Alliance, Greater New York Hospital Association, Mental Health Association of New York City, Mental Health Association in New York State, National Association of Social Workers – NYS, New York Association of Psychiatric Rehabilitation Services, New York Association on Independent Living, New York State Conference of Local Mental Hygiene Directors, New York State Council for Community Behavioral Healthcare, New York State Psychiatric Association, New York State Rehabilitation Association, Schuyler Center for Analysis and Advocacy, Supportive Housing Network of New York, UJA-Federation of New York. Small groups are working either to make it permanent or to end it.

3. Despite unconscionable efforts to wrongly portray them as violent, science is clear: people with mental illnesses are no more violent than the general public as was found in the 1998 McArthur Study on "Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods" Steadman et al in the Archives of General Psychiatry 1998): "There was no significant difference between the prevalence of violence by (mental) patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse."

And according to the New York Daily News, in a city that sees about 500 murders a year, New York City has had "five to six cases a year in which mentally troubled people committed" such attacks.

In fact, people with mental illnesses are 11 times more likely to be victims of violence, as was the conclusion of the 2005 "Crime Victimization in Adults with Severe Mental Illness" study, Teplin et al in the Archives of General Psychiatry August 2005.

It is important to note that a major proponent for a permanent aggressive version of Kendra's Law, DJ Jaffe of the Treatment Advocacy Center has said "from a marketing perspective, it may be necessary to capitalize on the fear of violence to get the law passed."

4. In the rare episodes of violence that do involve people with mental illnesses...from Andrew Goldstein to David Tarloff.., examinations into their treatment demonstrated that every single individual had not rejected mental health services but was instead repeatedly failed by them, typically the day or week before the tragedies. That's why the NYC Mental Health Care Monitoring Initiative was created as a primary recommendation of the 2008 New York State/New York City Mental Health-Criminal Justice Panel Report that investigated 4 episodes of violence involving people with mental illnesses in NYC. The initiative is advancing measures necessary to enhance provider responsiveness and continuity of care to at risk individuals and was part of a series of recommendations the Daily News termed "serious first efforts at providing better care to the mentally ill while better protecting New Yorkers at large from the tiny percentage of psychiatric patients who are potentially violent" (http://www.nydailynews.com/opinions/2008/06/15/2008-06-15_curbing_the_madness.html#ixzz0niEL5OBi).

5. As OMH Commissioner Michael Hogan recently wrote in the Buffalo News, the current budget crisis does not provide the additional service dollars that would be necessary if the program was expanded. He wrote "when Kendra's Law was passed in 1999, a number of new intensive mental health services were put into place ($120 million to build 2,000 additional community housing slots and 70 Assertive Community Treatment mobile teams). These expanded services were critical to the law's success. ....Gaps in the mental health safety net remain. But now, in the middle of the state's current fiscal environment, is not the time to address this" (http://www.buffalonews.com/2010/03/25/998407/five-year-renewal-is-best-for.html).

6. While 44 states have similar laws, it's important not to overstate the role these laws play in state and local mental health systems. Kendra's Law proponents themselves acknowledge that "only about eight to 10 states frequently use such laws" ("Torrey's Push for State Laws Sparks Growing Debate over Rights of Patients" Wall Street Journal February 2006).

7. A Columbia University research team recently acknowledged that they could not account for which program elements were responsible for higher outcomes and, accordingly, cautioned against "using our results to justify an expansion in coercion in psychiatric treatment. (Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Jo C. Phelan, Ph.D., Marilyn Sinkewicz, Ph.D., Dorothy M. Castille, Ph.D., Steven Huz, Ph.D. and Bruce G. Link, Ph.D. Psychiatric Services February 2010."

Editorial: Pass Extension Of Kendra's Law

May 29, 2010

A little more than a decade ago, New Yorker Kendra Webdale was killed when a schizophrenic man pushed her in front of a subway train. It was later discovered that man, Andrew Goldstein, had a history of hospitalizations for mental illness and had gone off his medications.

It led to a hue and cry - and, ultimately, to Kendra's Law, which forces mentally ill people to take their medication or face hospitalization.

That law is up for renewal again, and the state should to do precisely what it did when it was up for renewal in 2005 - it should extend the law but not make it permanent.

This would allow time for much-needed research on the effectiveness of court involvement vs. voluntary treatment. Mental health experts have differing views on the subject, and the law has always had its critics. Some have argued the law is tantamount to forced drugging and may violate people's constitutional rights.

The courts, however, have upheld the constitutionality of the statute, saying, in part, that the law helped individuals who have a history of forgoing needed treatment to safely survive in the community, while protecting society at large.

In fact, Kendra's Law has established a legitimate procedure for obtaining court orders to determine whether certain individuals with mental illness should be receiving and accepting outpatient treatment.

Some mental-health advocacy groups also take issue with how the law has been implemented around the state, noting that about two-thirds of those under court order are black or Hispanic. This, too, deserves more scrutiny. Extending the statute won't impede the program's main goals - to ensure those who need treatment are getting it and to protect others from possible threats - but it will give lawmakers more time to evaluate the true worth of the program. Letting the law expire doesn't make sense, but putting it on the books permanently isn't necessary either, at this point.

Lawmakers can make use so-called "sunset'' provisions to keep the law in place for another five years to gain a better understanding of how it is truly working. And that is precisely what they should do in this case.