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Email: jeanarnold@stigmanet.org
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Click for recap 1999-2005


KENDRA'S LAW UPDATES (2006 - 2013)
Assisted Outpatient Treatment (AOT)

aka Involuntary Outpatient Commitment


UPDATE  JANUARY 15, 2013:   NEW YORK EXTENDS KENDRA'S LAW THROUGH 2017

In a whirlwind response to the killing of 26 people (20 children) in Newtown CT, Gov. Andrew Cuomo signed a new package of firearm and mental health regulations, the NY SAFE Act, intended to control gun violence.  The act extends Kendra's Law from 2015 to 2017, expands some aspects of the law, and adds rules requiring professionals to inform authorities when one of their patients exhibits signs of potentially harmful behavior. The Safe Act raises many unanswered questions and treatment barriers such as patient/therapist trust .   The Kendra's Law extension seems premature considering the cautionary findings of independent evaluations in 2009 and 2010.  A new  independent evaluation is needed to replace the outdated in-house report of 2003 which the Legislature found unsatisfactory.   The only available outcome data were gathered by an in-house survey 6 months after the program began .  Not only is this outcome data quoted as though current, some of it applies to small segments of program recipients.  


UPDATE AUGUST 7, 2010:  NEW YORK EXTENDS KENDRA'S LAW UNTIL 2015

Despite a strong push by supporters of Kendra's Law to make it permanent, New York's lawmakers voted in June 2010 to extend the law for five years and further test its effectiveness.  The most recent evaluations (see list below) of the controversial law found that the key issue of voluntary vs. involunary psychiatric medication was far from resolved due to insufficient data.   Researchers also found troubling disparities in the law's implementation across the state. 


KENDRA'S LAW -- REPORTS AND EVALUATIONS OF ASSISTED OUTPATIENT TREATMENT (AOT):

An Interim Report on the Satus of Assisted Outpatient Treatment, January 1, 2003 The first data concerning outcomes of AOT  program - Kendra's Law (In-house report)

Final Report on the Status of Assisted Outpatient Treatment
Issued March 2005 by the New York State Office of Mental Health.  Repeats outcome statistics of 2003 Interim Report (In-house report)


1st independent evaluation of Assisted Outpatient Treatment (AOT)  2009
New York State Assisted Outpatient Treatment Program Evaluation

Independent evaluation issued June 30, 2009 by the New York State Office of Mental Health. This evaluation, led by Marvin S. Swartz et. al, was required by the New York State Legislature when it extended the law in 2005.   (The "Duke  Report")

2nd independent evaluation by Jo C. Phelan et. al,  published in Psychiatric Services 2010 
Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State 

This evaluation was published in February 2010 after its initial presentation at the annual conference of the Internationals Association for Forensic Mental Health Services, Vienna, Austria, July 14-16, 2009. 

3rd independent evaluation by Pamela Clark Robbins, et.al, published in Psychiatric Services 2010 
Assisted Outpatient Treatment in New York: Regional Differences in New York's  AOT program
This independent report includes several charts to illustrate the uneven implementation of Kendra's Law from 1999-2006 .


THE KENDRA'S LAW EXPERIMENT

A program requiring compulsory psychiatric medication


CONTENTS

INTRODUCTION
POSITION STATEMENTS
ARTICLES


INTRODUCTION
Of the 42 states that have laws permitting court-ordered treatment of psychiatric outpatients, only one, New York, actively uses its coercion statute (Kendra's Law).

As most states have become aware of coercion's limitations, they have spotted the weaknesses in Kendra's Law and are looking for better solutions. Some are turning to the people who use psychiatric services and applying their first-hand knowledge to innovative approaches.

Posted below are position statements and articles that characterize this new phase of mental health reform. An article, "Frightening Echo in Tales Of Two in Subway Attacks," (New York Times, 6/28/99, by Nina Bernstein) captures the essence of the forced treatment controversy that has hobbled mental health advocacy for more than a decade.

Another article offers an expert's comments on the law in operation, "Law and Psychiatry: Assessing Kendra's Law: Five Years of Outpatient Commitment in New York" by Paul S. Appelbaum, M.D.

A group of 7 articles describes New Mexico's ongoing outpatient coercion controversy. A proposed outpatient commitment law was defeated in 2006. The courts have twice rejected an Albuquerque ordinance intended to legalize compulsory medication in that city.


(Note: The following terms are used interchangeably: involuntary outpatient commitment, forced treatment, coerced treatment, mandated treatment, assisted outpatient treatment, leash laws. )



POSITION STATEMENTS


Below are links to position statements by key organizations listed in alphabetical order. These organizations are a rich source of additional links.


Bazelon Center for Mental Health Law
  • Bazelon Position Paper on IOC

  • "Studies of Outpatient Commitment are Misused"

  • Bazelon Issues: Commitment


  • MacArthur Foundation on Mental Health and the Law

  • MacArthur Research Network on Mandated Community Treatment

  • "Mandated Community Treatment: A Broader Framework for a Reasoned Discussion"


  • Mental Health America

  • Fact Sheet on Involuntary Outpatient
    Commitment



  • New York Association for Psychiatric Rehabitation Services

  • The Truth About Kendra's Law: Let's Make Policy Based on Facts Not Fear




  • ARTICLES


    Contents (For New Mexico articles, see last 7 listed below)

  • "Frightening Echo in Tales Of Two in Subway Attacks," by Nina Bernstein, New York Times, June 28, 1999

  • "Law & Psychiatry: Assessing Kendra's Law: Five Years of Outpatient Commitment in New York," by Paul S. Appelbaum, Psychiatric Services July 2005

  • "A Subway Nightmare Will Be the Focus of Yet a Third Trial," by Anemona Hartocollis, New York Times, May 23, 2006

  • Andrew Goldstein Receives 23-year Prison Sentence for Death of Kendra Webdale, by Jean Arnold, National Stigma Clearinghouse, Nov. 12, 2006. Also, an editorial by Michael Winerip, "Behind One Man's Mind," New York Times, December 26, 1999.

  • "Kendra's Law Teeters on False Premise," by Jean Arnold, National Stigma Clearinghouse, May, 2006

  • "Heartfelt Views of Kendra's Law, by Jim Belshaw, The Albuquerque Journal, February, 2006

  • "Not Everyone Backs Kendra's Law," by Jackie Jadrnak, The Albuquerque Journal, February 2006

  • "Debate Over Court Ordered Mental Health Treatment Moves to New Mexico," by Heather Clark, Associated Press, February 2006

  • "Judge Strikes Down Albuquerque's Kendra's Law," by Jim Ludwick, The Albuquerque Journal, October 19, 2006

  • "Question Remains: Does Kendra's Law pertain to John Hyde?", by Mark Sanders, The Albuquerque Tribune, October 18, 2006

  • Op-Ed: "Investment in Mental Health Pays Off," by Sarah Couch and Gay Finlayson, The Albuquerque Journal, February 22, 2007.

  • NEW!"City Will Keep Fighting for New Law," by Scott Sandlin and Dan McKay, The Albuquerque Journal, August 7, 2008.




  • The essence of the forced medication debate emerges in the following article.

    ARTICLE: New York Times, June 28, 1999
    Frightening Echo in Tales Of Two in Subway Attacks
    By NINA BERNSTEIN


    On the crowded Manhattan subway platform that evening, everything happened too fast, witnesses told the police.

    A man in the crowd was acting strangely. Someone demanded that he move. He wheeled around and shoved the nearest commuter onto the tracks as the No. 6 train screeched into the 51st Street station. The victim's legs were severed before anyone could intervene.

    But in the months before the attack at 5:45 P.M. on April 28, and even in the five hours leading up to that moment, signs of deterioration in the mental state of Julio Perez, 43, the homeless, schizophrenic man accused in the incident, went unrecognized, unheeded or untreated.

    The case strongly echoes that of another mentally ill man, Andrew Goldstein, accused in a subway attack in January that left a woman dead and provoked mounting criticism of New York State's mental health system.

    For months, Mr. Perez had been talking to friends and caseworkers about hurting people. In March he was kicked out of one program after becoming increasingly paranoid and belligerent. On the day of the attack, he had gone to a psychiatrist in the emergency room of a Veterans Administration hospital, to police headquarters and to the criminal courts building, complaining in each place about his treatment in a shelter for the mentally ill, and telling law enforcement officers that his enemies were following him, investigators said.

    In each instance that day, it appears from investigators' accounts and corroborating interviews, people with only scraps of information about Mr. Perez listened briefly and sent him on his way, to another part of the same disjointed system that had been shuttling him between hospitals, jails, shelters and the streets of New York since 1995.

    Friends of Mr. Perez described him as a gentle, poetic man in the yearlong periods when his mental illness was under control, and in New York, his only convictions were for fare-beating and for smoking marijuana in public. But a far more frightening picture of him existed in his native Puerto Rico, where Mr. Perez had a long record of criminal violence.

    Between his discharge from the United States Army in 1978 and his appearance in a New York City shelter in 1995, his convictions included attempted murder, aggravated assaults, robberies and weapons offenses, all clustered in short spurts between prison sentences of nine, three and two years, according to records obtained from the Interpol division of the Puerto Rico police department.

    Citing the confidentiality of patient records and the criminal case pending against Mr. Perez, who is being held on Rikers Island after being found competent to stand trial on an attempted murder charge in the subway pushing, few officials involved in his case would talk on the record.

    But a chronology pieced together from details some of them provided on the condition of anonymity, as well as from shelter records, other documents and interviews with five of Mr. Perez's friends, shows that his case has striking parallels to that of Mr. Goldstein. A schizophrenic man with a long history of violence, Mr. Goldstein is charged with pushing Kendra Webdale to her death in a subway station on Jan. 3.

    The Goldstein case has become central in an intensifying debate over the state's mental health system. Advocates for the mentally ill say financial constraints on hospitals have raised the threshold for psychiatric hospitalization, shortened stays for the acutely ill and eliminated thousands of long-term state hospital beds. Intensive case management and supportive housing in the community are in short supply, they say.

    But state officials defend the plan to continue shrinking the state hospital population, now down to 6,000 from 93,000 in 1953, and say that New York already spends more than $2 billion annually on supportive housing, more than any other state.

    And state legislators are debating ways to improve what critics call a makeshift system, cobbled together in ways that neither help the most severely mentally ill nor protect the public. The debate in Albany has largely centered on legislation that would allow mentally ill people to be forced into treatment. But lawmakers are also considering proposals to provide additional state money for community services for the mentally ill, such as supportive housing.

    The victim in the Perez case, Edgar Rivera, awoke from a weeklong coma without words of anger for his attacker.

    ''I have no legs, but at least I have my mind,'' Mr. Rivera, 37, said earlier this month from his hospital bed. ''This guy doesn't have that. I think I'm ahead.''

    Mr. Perez entered the city's shelter system for the homeless on Dec. 12, 1995, in a harsh winter when hundreds of men were left sleeping on the floor at the 30th Street Men's Shelter in Manhattan, the system's entry point. Like others in the overflow, Mr. Perez was likely bused late at night to the Flushing Men's Annex for a few hours in a cot, then dropped off to wander the streets again until nightfall, according to Patrick Markee, public policy analyst with the Coalition for the Homeless.

    In the next years, Mr. Perez would spend his nights in a series of shelters, getting brief stints of psychiatric hospitalization, sporadic outpatient treatment and psychotropic medication from a succession of institutions, depending in part, friends said, on whether he had slipped back into using street drugs, and whether his Medicaid card was still valid.

    Beginning in June 1996, when he was living at the 410-bed Borden Avenue Veterans' Shelter in Queens, he spent most days on an upper floor of a public assistance office building near Queens Plaza, in a program called Citiview Connections. The program, operated by Goodwill Industries, uses the ''clubhouse'' model of involving the mentally ill in the daily work of running the center, hooking them up with education and job opportunities and fostering friendships.

    By the spring of 1997, Mr. Perez had lost his bed at the veterans' shelter for missing curfews and had been arrested on charges of aggravated harassment, robbery and weapons possession, according to city shelter system officials, but there was no disposition of that case. He was assigned to the 900-bed shelter on Wards Island.

    In January 1998, Mr. Perez was flagrantly paranoid, hiding behind doors from imaginary enemies, according to accounts from friends that were confirmed by a mental health worker. But after a brief psychiatric hospitalization, he seemed more stable.

    When Mr. Perez was not working in the kitchen of the Citiview clubhouse or at its computers, friends said, he wrote poetry, drew pictures and spoke about wanting a home. ''He said he was tired of getting shifted around to all these different shelters and agencies,'' said Karen W., a friend who
    asked that her last name not be published.

    Mr. Perez befriended another woman at the Citiview clubhouse, but his mood darkened at the end of 1998, several friends said, when she rejected his declarations of love.

    ''Why should I want to become his girlfriend?'' asked that 35-year-old woman, who said she had coped with her own mental illness since age 17 and who asked that her name not be used. ''Who can want to marry a man who lives in a shelter?''

    By then, Mr. Perez was living in the Fort Washington Avenue shelter in upper Manhattan, in a 40-bed program for the severely mentally ill run by Columbia-Presbyterian Hospital under a contract with the city. By February 1999, he was complaining that guards and staff members there wanted him dead and that a fellow clubhouse member was trying to poison him, and was voicing violent fantasies of revenge.

    Troubled Patients Are Passed Over

    In early March, after a fight at the Fort Washington shelter left Mr. Perez with a bruised face, his escalating paranoia and belligerence were seen by caseworkers at the clubhouse in Queens as alarming symptoms of a psychotic relapse.

    They unsuccessfully recommended to psychiatrists at the shelter that Mr. Perez be hospitalized, a mental health worker familiar with the caseworkers' account said. At that point, for other members' safety, Citiview expelled him.

    Dr. Pablo Zapon, one of the psychiatrists at the Columbia-Presbyterian shelter program, was asked why Mr. Perez was not hospitalized, as caseworkers say they recommended. ''Things are not like they say, but I can't talk to you.'' Dr. Zapon said.

    Dr. Alan Felix, who runs the program, also said he could not talk about the case. His program has been praised by advocates for the mentally ill as among the best resources in a homeless shelter system under tremendous pressure.

    The advocates said it is harder than ever to get even the acutely mentally ill admitted to psychiatric hospitals at a time when shelters are being overwhelmed with patients who have a long record of violence. State institutions like Creedmoor Psychiatric Center in Queens continue to discharge patients from their dwindling population, and supportive housing programs, with far more applicants than they can accept, pass over the most problem-ridden.

    ''No matter how excellent that shelter is, it's still a shelter,'' said Susan Batkin, a lawyer specializing in mental health at the Urban Justice Center, an advocacy organization. ''The people with the most serious need for structure and support are not getting it -- that's the story, not that there was a bad judgment call by a psychiatrist.''

    Dr. Peter Weiden, a psychiatrist with no connection to the case and an authority on drug abusers who stop taking psychotropic medication, said the apparent fragmentation of Mr. Perez's care was standard.

    ''It's mix and match,'' he said. ''It's a huge problem and barrier to continuity of care. Basically, no one talks to anybody.''

    The expulsion from Citiview left Mr. Perez devastated and angry, his friends said. But there also were signs that he tried to return to medication that he had abandoned.

    Two weeks before the subway pushing, Karen W. said, Mr. Perez called her, panic-stricken, ranting that he needed medicine for his mind and that he could not get it because his Medicaid card had been canceled. Doctors and advocates say losing insurance coverage under Medicaid is a common problem for the mentally ill homeless, because welfare-to-work requirements and other eligibility hurdles at public assistance centers are so hard to negotiate.

    Two days before the attack, Karen W. said, he called her again, saying that he wanted to go back into a hospital, and asking her to meet him at Columbus Circle to accompany him. She said she waited for him for half an hour, but he did not show up.

    A Litany of Complaints Ends in a Subway Station

    At 12:30 P.M. on April 28, Mr. Perez entered the emergency room of the Veterans' Administration Hospital on 23d Street and First Avenue and asked to see a psychiatrist. Records available to the psychiatrist on duty, Dr. Alberto Gonzales, reflected that Mr. Perez had come to the V.A. for outpatient psychiatric care intermittently over the years, disappearing for long periods -- a common pattern, especially among the homeless, doctors said.

    ''He may have only bounced back to the V.A. when his Medicaid had run out,'' said Dr. Page M. Burkholder, a psychiatrist who formerly worked in the V.A. system with the homeless. ''Since he was in and out of the shelter system, he'd be a hard person to track down.'' She added, ''It sounds simplistic, but in the end it all does come down to housing.''

    Dr. Gonzales said he could not discuss the case, but according to investigators, Mr. Perez told Dr. Gonzales that he was upset about his living conditions at the shelter, and asked to be transferred back to the veterans' shelter in Queens. Dr. Gonzales told him, correctly, that any transfer had to be approved by the city shelter system, and that he would have to return to his current shelter to apply. Mr. Perez walked out, seemingly happy, the doctor told investigators, with an appointment for the outpatient psychiatry clinic the following day.

    ''The V.A. at 23d Street is very comfortable with the care provided to the veteran the last time he presented for care,'' said Peter Juliano, chief medical administrator. ''I can't explain what happened in those five hours -- it's terrible, terrible for the victim.''

    About 2 P.M., Mr. Perez passed through metal detectors in the lobby at 1 Police Plaza, and made a formal harassment complaint against the enemies he said were following him. As police procedures dictate,
    an officer filed a report.

    At 2:45, security guards at the nearby Municipal Building noticed a knapsack dropped on the sidewalk by a skinny, agitated man who fled when they approached. It was Mr. Perez, investigators say.

    At 4 P.M. he was inside the criminal courthouse at 100 Centre Street, outside a courtroom. Two court officers listened to his tale of unhappy living conditions and people who stalked him. They sent him on to the local police precinct.

    But investigators do not believe Mr. Perez went there. He was soon seen descending the stairs to the No. 6 subway station at Canal Street, and shortly before 5:45 P.M., when Mr. Rivera was pushed onto the tracks, Mr. Perez was spotted again, by a token clerk at the 51st Street station.

    ''I think the whole system failed,'' said a friend and fellow veteran who lived in a storm sewer in Riverside Park when his mental illness was out of control but who now lives in the Times Square Hotel, considered a model of supported housing.

    ''History is going to repeat itself,'' he said. ''I don't want to see any more people hurt out there.''

    Copyright 2006 The New York Times Company

    End of New York Times article, 6/28/99
    (reprinted using Fair Use Standard)

    The column below notes rarely discussed aspects of Kendra's Law..

    Source: Psychiatric Services 56:791-792, July 2005
    © 2005 American Psychiatric Association

    Law & Psychiatry: Assessing Kendra's Law: Five Years of Outpatient Commitment in New York

    by Paul S. Appelbaum, M.D.


    Outpatient commitment remains a controversial approach to the treatment of people with serious mental disorders who decline to participate in ordinary care (1). Forty-two states now have some form of statutory authorization for involuntary outpatient treatment (2), although surveys suggest that only a minority actively implement such laws (3). Indeed, some statutes appear to be written in such a way as to preclude outpatient commitment from being widely adopted (4). In recent years, New York State initiated a high-profile effort to develop an outpatient commitment system, and recently new data have become available that provide a look at where New York's efforts stand.

    New York's statute, often referred to as Kendra's Law, was passed by the state legislature in 1999 in the wake of the notorious murder of Kendra Webdale, a 32-year-old woman who was pushed in front of an oncoming subway train by a man with untreated schizophrenia. Although the man had sought treatment for his condition and been turned away for lack of available slots, and hence was not the prototypical target of outpatient commitment statutes, the attack galvanized the public and lawmakers in support of the proposed legislation (5). Like many of the newer statutes, Kendra's Law focuses on people with mental illness whose nonadherence has resulted in repeated hospitalization or incarceration, or has led to threats or acts of serious violence, and who could be predicted to deteriorate to a similar state without what the statute terms "assisted outpatient treatment" (6).

    Although New York's law largely resembles several other recent statutes, its implementation had some unusual aspects. Many states have adopted outpatient commitment laws without providing for the increased costs of developing more intensive services for a difficult-to-treat population. In contrast, New York appropriated funds to expand case management and other services and to pay for the care of patients who have been committed. Incremental funding support has continued to this day. Kendra's Law also had a sunset clause—which is uncommon in mental health legislation—that required reauthorization of the program by June 30, 2005, if it were to continue. Hence, at the time of this writing, New Yorkers are debating whether to extend their experiment with outpatient commitment. Finally, New York required periodic evaluations of the law's implementation so that its effects could be gauged, a salutary approach to public policy that is all too infrequently observed at either the state or the local level.

    As might have been anticipated given the contentious debate over outpatient commitment, the new statute was the target of a number of legal challenges. The most important of these was In the Matter of K.L., a test of the constitutionality of the statute that was ultimately decided by New York's highest court (7). K.L. was a patient with a diagnosis of schizoaffective disorder, a history of noncompliance, and a record of aggressiveness toward family members when he was experiencing decompensation. When a petition for outpatient commitment was filed, rather than merely claiming that he did not qualify for commitment, K.L. argued that the statute itself was constitutionally defective. His primary contention was that the statute violated due process because an order for assisted outpatient treatment was not predicated on a finding that the patient was incapable of making his own decisions about treatment.

    In his claim, K.L. relied on an earlier New York decision, Rivers v. Katz (8), which held that even involuntarily committed patients could not be medicated against their will unless they were determined by a judge to be decisionally incapable. But the New York Court of Appeals held that Rivers was not relevant here because, like most outpatient commitment statutes, Kendra's Law did not authorize involuntary medication. Even hospitalization of the committed outpatient required that the usual standards for involuntary admission be met. Indeed, the law's only "teeth" should patients fail to comply with a judicial order for outpatient treatment was to permit them to be picked up and detained for up to 72 hours to determine whether they met inpatient commitment criteria. A challenge to this provision on due process grounds was also turned aside. Reasoning that because outpatient commitment had involved a finding that the patient would be at risk of causing or suffering serious harm if noncompliant, the court held that the state had a legitimate interest in removing noncompliant patients from the streets to determine whether the prediction had been accurate.

    The irony in the court's decision should not go unnoted. Although heralded by advocates of outpatient commitment as an endorsement of the constitutionality of such laws, In the Matter of K.L. upheld the statute only because it lacked any direct mechanisms to enforce compliance with treatment. Outpatient commitment laws are often attacked by civil libertarians as being destructive of individual liberty; however, beyond the hortatory effect of a judge's admonition, and perhaps the prospect of a short-term hospital stay, they generally are without any coercive power. And although it is possible that courts in states that, unlike New York, do not require a finding of incapacity before medication can be administered involuntarily would uphold provisions for forcible administration of medication, legislative drafters have shied away from confronting this option.

    That Kendra's Law is constitutional, however, does not necessarily mean that it represents good policy. The latter determination depends on an assessment of the law's effectiveness. In this regard, the publication of the required final report on implementation of the statute by New York's Office of Mental Health should be of considerable interest (9). A previous study of a pilot project on outpatient commitment in New York City, the seed from which Kendra's Law grew, was disappointing in that it showed no significant differences in outcome between committed and control subjects (10). But the results of the study were compromised by problems in implementing the law, essentially leaving the question of effectiveness unanswered (11). Unfortunately, the new evaluation lacks a control group, which means that some of its conclusions will be open to varying interpretations. Nevertheless, it offers an interesting look at how the law is actually being implemented.

    Over the roughly five years covered by the study, more than 10,000 persons were referred to county-level assisted outpatient treatment coordinators for assessment of their eligibility (9). Of those, petitions were filed for 4,041 and granted in 93 percent of cases. Almost two-thirds of the patients who were subject to a court order had their commitments renewed after the first six months, for an average commitment period of 16 months. Committed patients had a mean age of 38 years and tended to be male, to have never married, to have a psychotic disorder, and to have substance use problems. Non-Hispanic blacks were disproportionately represented in the committed group, a finding that has already aroused concern (12). Over the three years before commitment, 97 percent of patients had been hospitalized, 30 percent arrested, 23 percent incarcerated, and 19 percent homeless.

    Outcomes were assessed at six months by clinicians who were involved in the patients' treatment; data were available for 2,745 people. Compared with the situation before commitment, rates of involvement in services had increased markedly—for example, for case management, 100 percent compared with 53 percent; for medication management, 88 percent compared with 66 percent; and for substance abuse services, 40 percent compared with 24 percent. Problems in self-care and community living dropped by 23 percent on average, and comparable improvements were seen in other functional domains. Harmful behaviors dropped by 44 percent, including a 47 percent decrease in physical harm to others. Arrest, incarceration, psychiatric hospitalization, and homelessness all dropped by between 74 percent and 87 percent. It seems clear that, as a group, patients did better with assisted outpatient treatment than they had previously.

    However, as with any program evaluation, there are several caveats to keep in mind, even though the findings have been trumpeted in some quarters as indicating that the law is a "remarkable success" (13). Ratings of patients' service use and functioning were made by case managers, who may have been unaware of some aspects of patients' functioning or predisposed to view the program as producing improvement. Long-term outcome data are not yet in, leaving open the question of whether patients sustain their gains, especially once they are no longer subject to the program. It seems clear that the current data will not satisfy many critics who contend that making a similar set of services available on a voluntary basis would have led to similar results, without the need for a judicial order. Only a randomized controlled comparison of voluntary and involuntary patients is likely to answer this question, and the data fall short of that standard.

    But that is not to say that we cannot learn something from the experience with Kendra's Law over the past five years. Statutes like this one, which reflect a new generation of legislation on outpatient commitment, are likely to be found constitutional by the courts. In implementing the law, New York State has been able to focus on a very ill and impaired target population and appears to have generated substantial improvements in these individuals' levels of functioning. The availability of funding for additional services probably made a big difference in the outcomes that are now being reported. And, perhaps the most certain conclusion of all, the controversy about the use of outpatient commitment is far from over.

    Footnotes:
     
    Dr. Appelbaum, who is editor of this column, is A. F. Zeleznik professor and chair in the department of psychiatry at the University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655 (e-mail, appelbap{at}ummhc.org).

    [There is new contact information for Dr. Appelbaum since the publication of this article :

    Paul S. Appelbaum, M.D.
    Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law
    Director, Division of Psychiatry, Law and Ethics
    Department of Psychiatry
    Columbia University College of Physicians and Surgeons

    Email: psa21@columbia.edu]

    References:
     Petrila J, Ridgely MS, Borum R: Debating outpatient commitment: controversy, trends, and empirical data. Crime and Delinquency 49:157–172,2003[CrossRef]
    Treatment Advocacy Center: Standards for Assisted Treatment: State by State Summary. Available at www.psychlaws.org/legalresources/statechart.htm
    Torrey EF, Kaplan RJ: A national survey of the use of outpatient commitment. Psychiatric Services 46:778–784,1995[Abstract/Free Full Text]
    Appelbaum PS: Ambivalence codified: California's new outpatient commitment statute. Psychiatric Services 54:26–28,2003[Free Full Text]
    Winerip M: Bedlam on the streets: increasingly the mentally ill have nowhere to go. That's their problem—and ours. New York Times Magazine, May 23, 1999, pp 12,13,45–49,56,65,70
    Laws of New York, 1999, Chap 408
    In the Matter of K.L., 1 NY3d 362 (2004)
    Rivers v Katz, 67 NY 2d 485 (1986)
    New York State Office of Mental Health: Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment, Mar 2005. Available at www.omh.state.ny.us/omhweb/kendra_web/finalreport/
    Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330–336,2001[Abstract/Free Full Text]
    Telson H, Glickstein R, Trujillo M: Report of the Bellevue Hospital Center Outpatient Commitment Pilot Program. New York, Bellevue Hospital Center, department of psychiatry, 1999
    Cooper M: Racial disproportion seen in applying "Kendra's Law." New York Times, Apr 7, 2005, p B-4
    Treatment Advocacy Center: Report shows success of New York's Kendra's Law. Press release, Mar 9, 2005. Available at www.psychlaws.org/pressroom/rls-kendraslawresults.htm


    Copyright © 2005 American Psychiatric Association.

    End of column

    (Reprinted with permission)
    ___________________________________


    Footnote by Jean Arnold, National Stigma Clearinghouse: For a clearer understanding of Kendra's Law outcomes, I suggest including the percentage of recipients involved in each category of behavior or services. both before and after 6 months of treatment. An example: 15% of recipients were in the "physically harm others" category when they entered the program; this figure dropped to 8% after 6 months.

    These figures are readily available in the tables in Kendra's Law Final Report, www.omh.state.ny.us/omhweb/kendra_web/finalreport/.) Unfortunately, they are rarely cited.


    _____________________________________






    A Subway Nightmare Will Be the Focus of Yet a Third Trial

    By ANEMONA HARTOCOLLIS   New York Times   May 23, 2006


    What happened to Kendra Webdale seven years ago was a New Yorker's nightmare: She was pushed in front of a subway train by a mentally ill man who had stopped taking his antipsychotic medication.

    Ms. Webdale, a 32-year-old journalist and photographer, was killed instantly. Her assailant, Andrew Goldstein, now 36, was convicted of her murder in March 2000 and was sentenced to up to life in prison.

    Now he will be tried again.

    Last December, the state's highest court overturned his conviction, saying that Mr. Goldstein's constitutional right to confront witnesses against him at his trial had been violated. Yesterday, the United States Supreme Court declined to review that decision.

    A spokeswoman for Robert M. Morgenthau, the Manhattan district attorney, said prosecutors would retry Mr. Goldstein, who remains in custody.

    Ms. Webdale's sister, Kim, said through the family's lawyer that the family would attend every day of the new trial, as they had his two previous ones.

    "What Kim said, was, it's going to bring up memories, but we're prepared to go through it a third time if necessary," the lawyer, Jay Dankner, said. "The family will be there as they were the first two trials, and await the jury's verdict."

    Natalie Rea, a lawyer for the Legal Aid Society who represented Mr. Goldstein in his appeal, said she was gratified that the Supreme Court had declined to hear the district attorney's appeal. "Obviously, they agreed with us," that the case did not present any new issues for the highest court, she said.

    In the meantime, Mr. Dankner said yesterday, there have been developments in a civil lawsuit filed by Ms. Webdale's family in 2000 against seven hospitals and clinics that cared for Mr. Goldstein before Ms. Webdale's death.

    He said he had obtained records detailing Mr. Goldstein's treatment in the weeks before he pushed Ms. Webdale to her death on Jan. 3, 1999, off the N-line platform at 23rd Street. "We see numerous prior assaults," Mr. Dankner said. "He was striking out at nurses and psychiatrists. This guy was a walking time bomb."

    In their civil suit, the Webdale family contends that Mr. Goldstein was discharged from North General Hospital in Harlem because the state reimbursement for 21 days of treatment had expired and there was no financial incentive to keep him there. Instead of going to a community-based facility, as he was supposed to, the lawyer said, Mr. Goldstein went back to his apartment, and stopped taking his medication.

    "Andrew Goldstein fell between the cracks in this system that we call mental health care in New York State as it existed in 1998 and 1999," Mr. Dankner said.

    In the seven years since Ms. Webdale was killed, her mother, Patricia, who lives in Fredonia, in upstate New York, has gone through a transformation. Mrs. Webdale, who has five other children, has become an advocate for the mentally ill, and she lectures across the country on the need for better treatment.

    She pushed for what became known as Kendra's Law, passed by the State Legislature in 1999. It allows families of mentally ill people, their roommates and mental health workers to petition the courts to require outpatient treatment for people who otherwise might not take their medication or follow their treatment plans.

    In an interview last winter, after Mr. Goldstein's conviction was overturned, Ms. Webdale said that in seeking supervision of the mentally ill, she is trying to prevent others from being victimized as her daughter was.

    The jury deadlocked in Mr. Goldstein's first trial, forcing a mistrial.

    In his second trial, his lawyer argued that Mr.
    Goldstein pushed Ms. Webdale onto the tracks while suffering from a transient psychotic episode, perhaps made worse by his failure to take his medication.

    The prosecution said Mr. Goldstein knew what he was doing, and had a history of using his mental illness as an excuse for bad behavior.

    Last December, the Court of Appeals, the state's highest court, ruled that the psychiatrist who testified for the prosecution should not have been allowed to testify about what other people, including Mr. Goldstein's former landlady, had told her about him, unless those people were available to be cross-examined by the defense.

    The state court cited a 2004 Supreme Court decision, Crawford v. Washington, in saying that Mr. Goldstein had a constitutional right to confront such witnesses.

    The prosecution's contention that Mr. Goldstein "was sane when he killed Kendra Webdale was a strong one, but we cannot say it was so strong that no rational jury could have rejected it," Judge Robert S. Smith of the Court of Appeals said, writing for the majority.

    End of Article


    Source:   New York Times

    Reprinted using Fair Use Standard>

    ________________________________________


    November 12, 2006 - News of the Week
    ANDREW GOLDSTEIN RECEIVES 23-YEAR PRISON SENTENCE FOR DEATH OF KENDRA WEBDALE

    Webdale Family is Spared Pain and Uncertainty of a Third Trial


    Seven years after Andrew Goldstein pushed Kendra Webdale to her death in a Manhattan subway, the case is finally closed. A negotiated agreement has spared the Webdales the agony of a third trial. On November 2nd, Goldstein was sentenced to 23 years in prison and five years of post-prison supervision.

    So why is there a sense of unfinished business? Perhaps the cause is remorse that Goldstein was falsely labeled a "treatment refuser" to clinch the passage of New York's compulsory outpatient treatment law. Or it may be a sense of lost opportunity: Goldstein's true story could have moved Albany to provide crucial psychiatric housing and treatment programs.

    Some answers may be found in an editorial written by Michael Winerip in 1999, "Behind One Man's Mind," (reprinted below from the New York Times). The editorial describes how the Goldstein case propelled Kendra's Law through the legislature in record time. Never mind that the facts about Goldstein were wrong; they had ceased to matter.

    EDITORIAL:

    Behind One Man's Mind

    By MICHAEL WINERIP


    Published: New York Times, December 26, 1999

    Treating mental illness is not one of society's big priorities, and public policy in the field often gets made in strange, circuitous ways. Last June the president held the first White House conference on mental illness; this month, Dr. David Satcher released the first surgeon general's report on the subject.

    But it is the states that are responsible for funding and treatment. And in New York, which has the nation's largest mental health budget, recent policy changes come courtesy not of the president nor the surgeon general, but thanks to one violent schizophrenic man, Andrew Goldstein.

    When the president and surgeon general discuss mental health policy, they sound cautious. They are not looking to commit new federal money to a problem that has been the states' burden for 150 years. The surgeon general's key conclusions -- that one in five Americans suffer some mental illness and that stigma is a main obstacle to seeking care -- have been common knowledge for years.

    But when Mr. Goldstein pushed Kendra Webdale to her death on the subway tracks last January, it set loose fear and outrage among the public and forced state politicians to take action.

    Public policy ginned up in the heat of battle is often a mixed blessing. Something gets done, though it may not have anything to do with the crisis at hand. In the Goldstein case, some changes -- $215 million budgeted for more supervised housing, more case managers and more beds for long-term state hospital care -- fit the facts of the case. Other changes -- like the passage of tougher legislation to force resistant mentally ill people to comply with treatment -- may or may not be a good idea, but had little to do with Mr. Goldstein.

    From the early news accounts of the murder it appeared that Mr. Goldstein had repeatedly been offered mental health services, but had refused treatment and medication. So the solution to preventing future Andrew Goldsteins seemed to be an aggressive new commitment law -- ''Kendra's Law'' -- and both the Republican governor and Democratic attorney general quickly drafted legislation.

    Then an article in The New York Times in May examining Mr. Goldstein's psychiatric record revealed a whole new set of facts.

    Mr. Goldstein had frequently and voluntarily sought long-term and short-term hospitalization, as well as supervised housing programs, but was repeatedly rejected because there were no vacancies in a system short of beds, programs and money.

    Whether tougher commitment laws even make a difference in getting dangerous people off the streets is a hard public policy question that has divided experts for years.

    In a mental health system with scarce resources, to make room for an Andrew Goldstein do you wind up pushing out into the street someone else who is equally troubled? In 1995, in an effort to assess whether New York needed to change its laws, the state financed a three-year pilot program at Bellevue Hospital with tougher commitment rules aimed at the resistant mentally ill.

    The results of that study, completed a month before the murder of Ms. Webdale, were inconclusive. Recently-released documents make it clear that the same Bellevue pilot program had two chances to get Mr. Goldstein off the streets but let him go. By sheer coincidence, he had visited the emergency room at Bellevue twice during the pilot program. And even though this was the period when he was regularly attacking strangers -- 13 in two years' -- the psychiatrists did not enroll him in the program. Each time, after a few days at Bellevue, he was released to live on his own, unsupervised. A tougher commitment standard had made no difference for the real Andrew Goldstein.

    In the end, the facts did not matter. Certain personal tragedies so unnerve the public -- the death of a Megan Kanka in New Jersey, the shootings at Columbine High School in Colorado -- that it becomes almost impossible for politicians not to act, and in a legislative instant new laws get made to register sex offenders, to expand gun control, to commit more mental patients. On Aug. 27, Gov. George E. Pataki signed Kendra's Law.

    That was just the beginning. By last summer the newly disclosed facts of the Goldstein case justified what mental health advocates had been arguing for years: a lack of state spending was crippling the system. To cut costs, the state had set quotas for reducing the patient population at every public hospital in New York, making it extremely difficult to get long-term care. Mr. Goldstein was a perfect example.

    In 1992, after assaulting three staff members at a mental health crisis program, he was hospitalized for eight months at Creedmoor state hospital in Queens. But when he attacked 13 people in 1997 and 1998, his psychiatrists could not get him into a state hospital for long-term care. Instead, he was admitted to short-term hospitals, and usually discharged within three weeks.

    The low point came in June 1998 -- six months before he killed Ms. Webdale. Mr. Goldstein was admitted to Brookdale, a short-term hospital, after he struck a woman on a subway car. On his third day at Brookdale, he attacked four hospital workers. Two weeks later he struck a nurse's assistant. The Brookdale psychiatrists applied to have Mr. Goldstein transferred for long-term care at Creedmoor.

    But the hospital put him on a waiting list, a common stalling tactic used at the time. Within days he was back on the streets.

    During the fall, Mr. Goldstein's trial kept public interest high and encouraged the news media to seek changes in state policy. In a rarity, The Times, The Daily News and The Post agreed in editorials on the need to put a moratorium on the reduction of state hospital beds, to finance more community housing programs and to support Kendra's law. And Governor Pataki listened.

    For a while the shark attack effect prevailed: if a mentally ill person committed a violent act it was perceived as part of a pattern -- another Goldstein -- and received prime news coverage.

    But there are dangers when journalists instantly try to cast news events in a public policy context. Last month, for example, New Yorkers were riveted by accounts of the search for a mentally ill homeless man who attacked a woman with a brick in midtown Manhattan. It seemed like another tragic failure of the mental health system -- another Goldstein! -- until the police arrested a career crook with a drug habit who was neither homeless nor mentally ill.

    End of article


    Reprinted using Fair Use Standard

    The following article by Jean Arnold, National Stigma Clearinghouse, appeared on the Antistigma Home Page

    May 12, 2006 - News of the Week


    KENDRA'S LAW TEETERS ON FALSE PREMISE

    System Reform Requires High Quality Programs, Not Coercion Laws

    The guru of forced psychotropic medication for outpatients, Dr. E. Fuller Torrey, recently acknowledged in an NPR interview that although 42 states have court-ordered treatment laws, they are rarely used. Why? Perhaps Torrey's organization, the Treatment Advocacy Center (TAC), is itself at fault.

    TAC has linked coercion laws to brutal deaths, winning their passage in the glare of highly emotional publicity. When the full facts emerge, however, they often reveal a trail of negligence by budget-squeezed poorly-coordinated mental health facilities.

    "Bad case, bad law," is a cliche that may explain states' caution in applying their court-ordered treatment laws.

    TAC perfected its "public safety" approach to legislation in 1999, after the fatal encounter of Kendra Webdale and Andrew Goldstein in a Manhattan subway station.

    Under TAC's guidance, a family's overwhelming loss came to symbolize a menace to every New Yorker.

    To launch "Kendra's Law," TAC first shoehorned Goldstein into the role of a "medication refuser" who lacked insight into his psychosis.

    Several months of intense publicity overwhelmed the actual facts of Goldstein's record, including findings by the New York Times that he had tried in vain to get the help he knew he needed. (Click NYTimes article)

    As the truth emerged, Goldstein's psychiatric history is an appalling account of mistakes made and opportunities missed by the psychiatric facilities he turned to, often voluntarily, for help. (Click official state report) In spite of all this, a vengeful tone at his trials helped put him in prison, possibly for life, and his mislabeling continues to re-surface in the press.

    Innovative states are proving that high quality programs are successful without a law enforcement approach. The appeal of TAC's coercion campaign will fade further as states shift to treatments developed in consultation with people with first-hand knowlege of psychiatric conditions. These programs are promoted by the Bazelon Center for Mental Health Law, The Presidents' Commission on Mental Health, and SAMHSA.


    Footnote:

    Are forced treatment laws redundant? Has the Treatment Advocacy Center's aggressive and fearmongering stance on forced medication hindered system reform?

    Here are two critics' views on the law's redundancy:

    1999 - "The focus of coercion upon the patient is, I submit, a misdirection of energy. Coercion is needed, but to enforce the laws already on the books that are routinely disregarded with impunity, either because of the scarcity of resources or because of conflicting pressures." Source: Clarence J. Sundram, former Chairman (for 20 years), NYS Commission on Quality of Care. "Misdiagnosis and Non-Solutions," May 20, 1999, a statement in opposition to the then-proposed Kendra's Law.


    2006 - " 'Kevin's Law' [Michigan's forced-treatment law] is unnecessary because we judges already had the authority to order medication on an outpatient basis." The quote is from Judge Patrick J. McGraw, Saginaw County Circuit Court Family Division.

    The article notes that "Mr. McGraw, who handles nearly all mentally ill committments in the county, says he occasionally orders outpatient medication but has yet to use 'Kevin's Law' for any person." Source: "Forced Drugging," by Scott Davis, The Saginaw News, March 1, 2006.


    A Comment on TAC's Inflation of Kendra's Law Outcomes:

    In March 2005, the New York State Office of Mental Health released an analysis of outcome data on 2,745 recipients of New York's AOT program, Kendra's Law.

    The Treatment Advocacy Center (TAC) has selected data out of context and is using it to win support for similar laws in other states.

    TAC is publicizing high rates of improvement without explaining that only a modest number of AOT's 2,745 recipients improved significantly between the time they entered the program and 6 months later.

    For example, TAC reports that AOT recipients experienced 87% less incarceration after AOT.

    What TAC doesn't explain is that prior to entering the AOT program, 23% of recipients experienced incarceration, and after 6 months in the AOT program, 3% experienced incarceration. The state's AOT report describes this as an 87% improvement for 23% of AOT's 2,745 program recipients. (To complicate matters, some data analysts would consider this a 20% improvement.)

    How does TAC's skewing of outcomes poison the AOT debate? Consider the preposterous claims of a forced treatment proponent in Maine:
    "In New York, 91% of those who were not taking medications began taking them, just because that law was on the books" and "arrests for petty and violent crimes involving people with mental illness dropped 78% and millions of dollars in hospital costs were freed up for community services." Source: Maine Times Record, March 10, 2005


    We welcome readers' comments. Email stigmanet@webtv.net

    End of Article
    ___________________



    THE NEW MEXICO CONTEST: In February, 2006, a fierce contest in New Mexico ended in victory for the opponents of involuntary outpatient commitment. In October 2006, and again in August 2008, the district court struck down a local Kendra's Law adopted by the city of Albuquerque. See articles below (earliest are last) for reactions to the New Mexico controversy. (Reprints protected by Fair Use Standard)

    ARTICLE:

    City Will Keep Fighting for Mental Health Law

    By Scott Sandlin And Dan McKay   Albuquerque Journal   August 7, 2008

     
    Albuquerque officials reacted quickly this week after a second court struck down the city's Kendra's Law clone, which would have required forced medication of some people with mental illnesses.
     
    Mayor Martin Chavez said he would pursue remedies in both the state Supreme Court and the Legislature after the New Mexico Court of Appeals ruled that the city's Assisted Outpatient Treatment ordinance was preempted by a raft of state mental health laws, both civil and criminal.

    "We'll keep fighting," Chavez said Wednesday.

    Mental health and civil rights advocates, meanwhile, said the focus should be on fixing a broken and wholly inadequate mental health service system. They, too, will be back at the Legislature with proposals.

    Mental health advocates said existing law has mechanisms for getting a substitute decision-maker appointed when a person is incapacitated.

    Despite "fearmongering" by its backers, the city ordinance would not have prevented tragic circumstances in which people have died, said Nancy Koenigsberg, a staff attorney at Protection and Advocacy. The organization was created to protect the rights of people with mental illness.

    In both New York, where Kendra's Law was enacted, and in New Mexico, people with mental illness were trying to access care in the system and couldn't get it, she said.

    "Even the ordinance that was struck (down) acknowledged that for any kind of treatment to achieve its goal, it must be linked to a system of comprehensive care in which state and local authorities work together to ensure outpatients receive case management or special services. That's great. We agree with that. And it doesn't exist," she said.

    The state Medicaid program has cut back case management services, and other providers of outpatient mental health services have cut them back or eliminated them altogether, Koenigsberg said.

    "You're talking about a person with a chronic illness who needs help to get to appointments or address barriers to work getting to an aid program — and they are few and far between," she said.

    Chavez argues the city ordinance is necessary to keep from putting "innocents at risk." In 2005, a mentally ill man was accused in the killing of two police officers and three other people.

    Asked about criticism that not enough mental-health services are available, Chavez said opponents can "say that to the widows of the police officers" and their families.

    The ordinance was crafted carefully and
    applies to "just a narrow slice of people," Chavez said.

    He described opponents as merely a small, vocal group.

    Andrew Penn, a senior staff attorney at the Bazelon Center for Mental Health Law in Washington, D.C., praised the appeals court decision by Chief Judge Jonathan Sutin for "confirm(ing) the right of an individual to make his or her own mental health treatment decisions. That is something we find so important in terms of individual rights and dignity."

    He said studies have shown that forced treatment doesn't work.

    "I don't think the solution in keeping people safe lies in forced commitment. It lies in more effective community services," he said.

    Peter Simonson, director of the ACLU of New Mexico, said the city ordinance was "overreaching," targeting an overly broad group.
     
    "The city wants to be able to medicate people who refused to consent to psychotropic drugs, while the Legislature carefully preserved the right of a person to refuse (treatment). We're talking about drugs that can have a long-term, permanent effect on your neurological system and can be very damaging," he said.

    Had the law withstood the challenge, there conceivably could have been a situation where someone forced to accept medication couldn't have paid for it — and had to be incarcerated, Simonson said.

    "The backdrop for this whole thing is a broken system. Not only did the city law ignore that, but it also penalized a person for being at its mercy," he said.

    Koenigsberg said a newly formed network of mental health advocacy groups worked to create proactive legislation, including two companion bills introduced in the last legislative session by Rep. Nathan Cote, D-Las Cruces. One would have created safe houses for people who need behavioral health support but not hospitalization. Another would have recruited and trained quick-response teams statewide for people experiencing urgent behavioral health needs.

    They'll be back with the proposals again.
    "I know there will be other things brought forward before the Legislature again — and that's where it belongs. It is a statewide issue. ... It shouldn't be in the courts," Koenigsberg said.

    Chavez had pushed for a statewide version of the law before Albuquerque enacted its own. He said the city will continue lobbying for such a law while pursuing its options for appeal.

    Chavez, a lawyer himself, said the city's legal team believes there's a good chance of success if the city continues litigation.
     
    "I really expected to do better in the Court of Appeals," he said.

    Most states already have a version of Kendra's law, Chavez said, calling the recent court decision "troubling."
     

    End of Article



    OP-ED: Investment in Mental Health Pays Off
    by Sarah Couch and Gay Finlayson, Bernalillo County Local Collaborative
    The Albuquerque Journal  February 22, 2007

     
    New Mexico ranks last in the nation in per capita spending for people with behavioral health needs ($28.80). We have an opportunity to raise this rank during the current legislative session. Instead, both the governor's and the Legislature's budget proposals actually cut state spending in this area of critical need.
     
    Spending cuts in this area cost us in every other system of the state. It will have a direct impact on your life— immediately. A system that already is inadequate for children who are at risk will become even more depleted and incapable of helping them improve their mental health.
     
    The executive proposal argues that cutting expensive residential services is a good idea, but the proposal makes no alternative services available to fill the gap. In effect, we are abandoning our children to systems that are already overburdened— schools, juvenile justice and foster care.
     
    There are myriad studies that prove prevention works. Prevention would cut cost of care across the lifespan, improve quality of life for people with mental health struggles and their families, and reduce the burden placed on our overtaxed systems. Prevention involves treatment options and access to care. Because we aren't proactive, children founder, then move into the adult mental health care and criminal justice systems.
     
    For adults seeking services— sitting on therapists' waiting lists for months— there are few options. Jail or prison inmates are often released with a limited supply of medication, and rarely qualify for indigent care. Those who live outside Bernalillo County can't get help in the county.
     
    Those with the tenacity and persistence, or family support to figure out how to maneuver through the systems to get on waiting lists, still find it almost impossible to access services. Someone who needs crisis care, such as inpatient hospitalization, is generally turned away. There is no state funding to pay for medication for those not on Medicaid or a private insurance plan.
     
    The current system and its attitude of indifference forces too many into a life of isolation, feeling hopeless and abandoned and in more cases, angry and frustrated.
     
    Legislation proposes to fix this by forcing treatment on people deemed to present an imminent danger to themselves or society. Does this mean that the best way to secure treatment is by threatening the lives of others?
     
    You can't mandate treatment for people society thinks need it when the treatment doesn't exist. Involuntary outpatient commitment or treatment is based on the false premise that society can predict who may become a danger in the future.
     
    Mandating treatment is difficult because treatment should be as individual as the person with mental illness. Medication works for some. Others choose yoga, social interaction, exercise, balanced eating, acupuncture, good sleep patterns, curanderas, chiropractors. These treatments are just as, if not more, effective than the options outlined in the forced outpatient bill, and they don't have the debilitating side effects.
     
    It is arrogant to assume we know what treatment will work or that only certain types of treatment are viable. Our arrogance should come when we become a state that cares for its residents. Guaranteeing our position as last in the nation on spending for behavioral health services by cutting the little that is available makes no sense.
     
    We have to rise up in a grassroots effort to force those who control our money to pay attention. Instead of shooting for the stars or buying trains, let's put funding where we know it will impact the residents of New Mexico. We know what will improve the quality of life, the workforce, poverty, crime.
     
    We have the facts and figures— we have to have the sense and courage to make the right decisions. Leaders and legislators— invest in the best resource New Mexico has— its people.

    End of Article
    _______________

     
    Heartfelt Views of Kendra's Law
    By Jim Belshaw   The Albuquerque   Journal  February 12, 2006

     
    Two people write, one diagnosed with a mental illness, the other the father of a woman diagnosed with a mental illness. I cannot begin to offer enough space to their words, so I'll have to settle for what amounts to a prologue for two voices.
     
    The subject is Kendra's Law, legislation allowing a court to commit certain mentally ill people to mandatory outpatient treatment. One writer supports it; the other doesn't.
     
    David, whose daughter is diagnosed with mental illness, recognizes the fears of those opposed to Kendra's Law but believes that in an arena holding only difficult choices, the law is the best one. (I have known him professionally for several years. He asked that I not identify him fully on his daughter's behalf.)

    "For some people, dealing with mental illness gives rise to passionate advocacy," he writes. "It can be a very vexing subject. Its complexity as public policy coupled with the infinite ways in which behavior swerves off-course are not easy to hold in tandem or steady."
     
    The other writer is Sarah Couch, a young woman diagnosed with mental illness and a gifted, compelling writer.
     
    She spoke briefly at a House Judiciary Committee hearing last week. Earlier in the day, she read a statement at the first press conference of her life, not knowing reporters would ask questions later, questions about her diagnosis (bipolar), questions about her medications.
     
    "Some of those questions were hard to answer," she said.
     
    More than three weeks ago, she wrote a letter to Mayor Martin Chavez. She said she has received no reply from City Hall. 

    "Mr. Mayor, I tend to believe that a society can be assessed by the care it gives to its sick, its poor, and its children; it is only as good as its most vulnerable members. As it stands, Albuquerque isn't doing a stellar job. I could run through the list, but surely you know it.  

    "You can remove the rights of people with mental illness, but really, Mr. Mayor, that isn't a step toward anything; it is a step back to the days when they threw us in asylums and tossed us in pools of ice water. 

    "Mr. Mayor, if you really want to problem solve Albuquerque's mental health care crisis, you can invite me and my friends to your table, allow us to keep our rights, and give us a voice in the decision-making process. You'd be surprised what we can teach you, if you'd only listen." 
     
    David calls the $2 million being discussed in the Legislature a "down payment," saying a minimum of $15 million is needed to fund services properly.

    He says the issue is sometimes like a civil war, splitting not only proponents and opponents, but sometimes families, each side passionate, each side wanting to do the right thing.

    "For almost all of us, our feelings mix both great certitude and incredible vulnerability," he says. "When all is thrust into the 'competitive arena' of legislation, you do indeed get strongly held views pushed forth both in support of and in opposition to mental health legislation. It's understandably hard for some, including legislators, to know to whom (they should) listen since the respective stories can be so compelling."
     
    Sarah's numerous writings on my desk present too many choices, too many words, too little space into which I can put them. I'll end with these.

    "Many of us treasure each breath we take because we have been dangerously close to losing our lives; some of us have tried to take them ourselves. We struggle to find a balance between sick and well knowing that we always carry illness with us and that, even when we are taking our medications and all necessary preventive measures, at any moment it could rear its ugly head, strike out, and carry us under ...

    "Sometimes it feels like an injustice to have been served with the life sentence of a mental illness, let us share it with you. We know you can't understand unless you've been there, we don't expect you to. Help us to see that the voice we have kept silent for so many years is there and waiting to speak up and be heard, and that maybe changing the world isn't such a far-fetched idea if we start with ourselves and work out from there." 

    End of Article
    __________________



     Not Everyone Backs Kendra's Law
    by Jackie Jadrnak   Albuquerque Journal Staff Writer    February 7, 2006

     
    Even though John Hyde's name has been invoked repeatedly in support of a Kendra's Law, you haven't seen his family members speaking out in support of it.
     
    And there's a good chance you won't.
     
    Robert Hyde, John Hyde's brother, said he doesn't want to take a position on the "politically charged" issue. Kendra's Law would allow a judge to mandate that people with mental illnesses comply with a treatment plan.
     
    Some say it would be a life-saver for those struggling to convince mentally ill family members to take their medications. Others say it infringes on civil liberties and adds coercion to a system that doesn't provide enough services.
     
    In an e-mail responding to a request for comment, Robert Hyde wrote, "... I am disgusted with the way our community leaders, legislators and politicians are citing the John Hyde case to push their agenda."
     
    John Hyde, who was charged with killing two police officers and three others, had his schizophrenia under control for more than 15 years, Robert Hyde said.
     
    The family doesn't know details of what happened to John Hyde's mental state. They do know he had been given new medications that appeared not to work well, and that he had sought to switch psychiatrists and drugs. When he was unsuccessful, he apparently stopped taking the medications, Robert Hyde said.
     
    As John Hyde destabilized, family members contacted his mental health providers and asked for help. That help never came, Robert Hyde said.
     
    Later, when John Hyde was taken to an emergency room for a mental health evaluation, the doctor who signed the pickup order never saw him before he was released, Robert Hyde said.
     
    The way he sees it, the problem was lack of response from the mental health system, not a need for additional laws.
     
     "I am totally in favor of making positive changes to the mental health care system," Robert Hyde said, adding that those changes should be increased funding, improved services and better coordination among care providers.

    End of Article
    ________________



     
    Debate Over Court-Ordered Mental Health Treatment Moves To N.M.
    By Heather Clark  Associated Press  February 3, 2006


    SANTA FE - A schizophrenic who had stopped taking his medication was accused of killing five people in Albuquerque last year. Another mentally ill man was shot to death by police after he shot and injured an Albuquerque police officer.

    Last month, Jennifer San Marco, who had a history of psychiatric problems and behaved bizarrely while living in New Mexico, bought a gun in a Grants pawn shop and shot herself and seven other people to death in Southern California.

    Cases like these have reignited national debate over whether mentally ill people judged to be a threat to themselves or the community should be forced into court-ordered treatment.

    The issue surfaced in New Mexico this month as the Legislature considered a bill that would allow judges to order "assisted-outpatient treatment'' for mentally ill people. The bill's fate is unclear as end of the session approaches Thursday.

    Supporters say the measure would be a way to get people the help they need when they are unable to choose treatment themselves. Such treatment could include medication, therapy sessions or alcohol and drug counseling.

    But those who work with mentally ill people are divided over the issue.

    "This is the most contentious issue nationally in the mental health community,'' said Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services.

    Rosenthal and other opponents of the bill held a news conference at the capital last week to argue that the proposal dehumanizes mentally ill people and could drive some of them away from caregivers because they fear being forced into treatment.

    The bill, sponsored by Rep. Joni Marie Gutierrez, D-Las Cruces, provides court-ordered treatment for mentally ill people who are unlikely to survive safely in the community without supervision and are unlikely to get treatment voluntarily.

    The measure has some powerful bipartisan supporters, including Democratic Gov. Bill Richardson, Republican U.S. Sen. Pete Domenici and Democratic Albuquerque Mayor Martin Chavez.

    Chavez has said that if the bill fails, he will propose an ordinance for New Mexico's largest city, which had shootings involving mentally ill people in 2005 and 2003. John Hyde is accused of killing five people, including two police officers, last August. In 2003, Duc Mihn Pham, who had a history of mental disorders, was killed by police after he shot and wounded a police officer.

    Should the bill pass, New Mexico would become the 43rd state with such a law, said Mary Zdanowicz, executive director of the nonprofit Treatment Advocacy Center in Virginia.

    Zdanowicz estimates that under the law, judges would order about 75 people a year into treatment in New Mexico.

    "This is an important law for a small group of people with severe mental illnesses who are too sick to know they need treatment and to access treatment voluntarily,'' she said. "It has been shown to reduce arrests, homelessness, hospitalization, violence and victimization of the person with the mental illness.''

    But Rosenthal, who has bipolar and attention deficit disorders, said he wants to stop New Mexico from adopting a law modeled on a New York law called "Kendra's Law.'' That law was named after Kendra Webdale, who died in New York City in 1999 after being shoved in front of a subway train by a schizophrenic who did not take his medication.

    New Mexico's proposal is a quick political fix in the wake of high-profile tragedies that deflects from efforts to boost mental health care funding and improve access to services, Rosenthal said.

    "You don't need to force the patients into care; you have to force the system to better respond,'' he said.

    But New York Mental Health Commissioner
    Sharon Carpinello wrote in a Feb. 8 letter to New Mexico Health Secretary Michelle Lujan Grisham that the law in her state is "extremely successful'' and a newly formed panel began meeting in January to expand it.

    Nancy Koenigsberg, legal director of Protection & Advocacy System in Albuquerque, agreed. She says the state should first see whether a Behavioral Health Purchasing Collaborative launched last July will be successful in better coordinating mental health care across state agencies to make the system more efficient.

    Some mentally ill people and their families describe struggling to get hospitalization and medication for themselves or their family members.

    Sarah Couch of Albuquerque, who has bipolar disorder, said that when she took a turn for the worse a year and a half ago, she made repeated phone calls asking to be hospitalized and to get medications.

    The 27-year-old woman said she thinks the bill would have a chilling effect.

    "If there had been a Kendra's Law when I was
    first struggling, I would not have had the courage to be evaluated,'' she said. "If the law passes, I will carefully censor what I share with my doctors and my family members.''

    But Will Stevens of Albuquerque, who has two sons with bipolar disorder, said he believes the law would help families get their children into care more quickly.

    One of his sons was recently jailed in California, he said.

    "I hope the California version of Kendra's Law will help him seek the treatment that we as parents couldn't get him to seek,'' Stevens said.

    John Hyde's brother, Robert, said he's not sure whether he supports the bill. He questions whether it would have made a difference in his brother's case.

    "The mental health care system in New Mexico is in shambles and something needs to be done, or it's going to happen again and more families will be devastated by this,'' he said.

    End of Article
    ________________



    ________________________________________

    Two articles concerning the blocking of a local "Kendra's Law" by court injunction in October 2006.

    Article 1:

    Judge Strikes Down Albuquerque's Kendra's Law

    by Jim Ludwick
    Albuquerque Journal Staff Writer
    October 19, 2006
       
    Albuquerque's version of Kendra's Law was struck down Friday in state District Court.

    Judge Valerie A. Huling ruled that the local ordinance dealing with mandated treatment for mentally ill residents conflicts with state law and exceeds the city's authority. She issued a permanent injunction that blocks the city from enforcing the ordinance.
       
    Huling said the matter "involves complex issues and illustrates the difficulty of a municipality acting in an area of statewide concern that should be left to our Legislature."
       
    Mayor Martin Chávez said the city will appeal the ruling and seek legislative approval of a statewide law.
       
    Most states have a Kendra's Law, but Albuquerque was the first city in the United States to adopt a local version. It would have forced mentally ill people to take medication if a court decided they would be potentially violent otherwise.
       
    Chávez originally sought a state law, but he proposed a local ordinance when state legislation wasn't enacted. The state legislation won unanimous approval in the House during the last session, but the Senate didn't bring it to a vote.
       
    "I have always contended this should be a state law. Albuquerque acted only when the state Legislature failed to act," Chávez said.
       
    He said the judge's decision "has made Albuquerque a less safe city than it would have been."
       
    Peter Simonson, executive director at the American Civil Liberties Union of New Mexico, said he's "thrilled" by the ruling.
       
    "This was a resounding victory," he said, adding that an appeal "would be a waste of time. ... They would be wasting their time and the taxpayers' money."
       
    City Councilor Debbie O'Malley, the only member of the council who voted against the ordinance when it was approved 8-1 in September, said Friday that it wasn't justifiable or effective.
       
    "I didn't think it was a good law. Apparently, the judge felt the same way," O'Malley said.
       
    Lt. Gov. Diane Denish issued a statement Friday saying the topic "is a very serious mental-health and public-safety issue that needs to be dealt with on the state level."
       
    Denish said she looks forward to working on a proposal for the coming session of the Legislature, which begins in January.
       
    The judge's ruling did not deal with questions of constitutionality and did not suggest a state law would be improper. Rather, her 13-page opinion centered on arguments about whether a city in New Mexico could have such a law.
       
    Huling said the law conflicts with the Mental Health Code and the Mental Health Care Treatment Decisions Act, which provide statewide treatment standards and legal rights.
       
    State law deals with emergency detention, evaluation, care, and the right of competent patients "to refuse psychotropic medication and other invasive treatment," Huling said.
       
    "Only if mentally ill individuals are found, through extensive procedure including a hearing and court order, to be incompetent, can a court order the appointment of a treatment guardian, who may then petition a court to forcibly administer treatment," Huling said.
       
    She also said the local law exceeds the authority of city government.
       
    Kendra's Law is a concept named after a woman who was pushed in front of a New York subway train by a man with a history of mental illness.
       
    The Albuquerque law was challenged in court by the Protection and Advocacy System and four people who have been diagnosed with mental illnesses. The American Civil Liberties Union helped with the case.
    ----------------

    Article 2:

    The Kendra Question

    The fight over Kendra's Law may be over, but the question remains: Does it pertain to John Hyde?

    By Mark Sanders 
    Albuquerque Tribune
      
    October 18, 2006

    In August of last year, when John Hyde infamously put Albuquerque in the national spotlight, not many locals were talking about Kendra's Law. There was no reason, really, until the ill-fated day when Hyde shot and killed five city residents, including two police officers. Soon afterward, the law—which makes mental health outpatient care mandatory under certain circumstances—became synonymous with the Hyde killings.

    Hyde wasn't taking his meds at the time of the shootings, and supporters of the bill (similar legislation has already passed in 42 other states) contended that the murders might have never occurred if Hyde was ordered by law to do so.

    Last week, District Court Judge Valerie Huling struck down a local Kendra's Law that would have made Albuquerque the first city in the country with its own version of the ordinance.

    But even if the controversial law had been in place on Aug. 18, 2005, would it have prevented John Hyde from killing five innocent people?

    "He would not have been subject to this," says City Council President Martin Heinrich, who voted for the local Kendra's Law last month in a near-unanimous decision by the Council (only Councilor Debbie O'Malley opposed the bill). "The tragedy of Hyde is more of an indictment of the mental health system as a whole," Heinrich says, "than a prescription of Kendra's Law."

    He cautions, "It's not fair to use him as a poster boy in this case."

    Councilor O'Malley agrees. As the City Council's sole opponent to the legislation, she admits there was a lot of pressure for her to vote in favor of Kendra's Law. She might be seen as soft on crime, or worse yet, as insulting the family members of those who died. "I don't know what the [political] fallout will be from this," she admits.
    Yet O'Malley stands behind her decision. She says the local version of Kendra's Law, whose defeat is being appealed by Mayor Martin Chavez, is a matter of mispla ced priorities.

    "It's reactive," she says, adding that it's a quick-fix scheme that is neither constitutional nor effective. While the ordinance may comfort victims' family members and fear-stricken members of the community, she believes "it unfairly targets the mentally ill based on what they may or may not do."

    Asked whether Kendra's Law would have affected John Hyde, O'Malley echoes Heinrich's statement: "There is some real doubt."

    A Talk with Mr. Hyde

    John's brother Robert is an outspoken critic of both the local media and the City Council for their treatment of the Hyde case. Robert's been his brother's close ally through John's long bout with schizophrenia, a condition Robert suspects has been around for all of John's 50 years but only intensified in the past few.

    The local ordinance, which the mayor hopes will receive statewide approval (despite the Albuquerque defeat), contains eight factors that determine a mentally ill person's eligibility for mandatory care. Since John Hyde's medical records are sealed, Robert is about as close as we can get to knowing his brother's history.
    "He was begging for help," says Robert, who says John was never noncompliant with a treatment program (one of the eight criteria). "He was trying to get the psychiatrist to change his dosage," since the medication John was taking, Robert says, simply was not working.

    Another requirement for mandatory outpatient treatment: Mentally disabled people have to be jailed or placed in a state correctional facility twice within the past three years; John wasn't, says Robert, though he did seek treatment at Presbyterian Hospital.

    Lastly, John didn't have a history of violence, and he never resisted treatment, says Robert. John would have needed to meet all these requirements to be placed in an assisted outpatient treatment program; according to his brother, he met none of them.

    Mayor Chavez, who has pushed hard for the legislation (and signed it into law nine days after Council approval), was unreachable for comment, though Assistant City Attorney Greg Wheeler offers his opinion. "I'm sure that was a factor," Wheeler says, when asked whether the Hyde case was behind Chavez' decision to push forward with the ordinance. Wheeler won't comment on whether Hyde would have been subject to Kendra's Law due to a lawsuit filed by nonprofit human rights organization the Protection and Advocacy System against the city--which contends that Albuquerque's Kendra's Law violates New Mexico's constitution.

    Robert Hyde is outraged at the very notion that his brother has become a rallying cry for Kendra's Law supporters. He has personally contacted local televisio n stations to ask that they not show footage of John post-arrest, wearing a bright orange county-issued jumpsuit. It's misleading to viewers, he says, when local TV outlets show Hyde during segments on Kendra's Law.

    He recalls a recent call-in radio show, during which an upset caller said he would pull the switch on John Hyde's electric chair, if and when the time came. Robert then mentions City Councilor Ken Sanchez' statement at a news conference in August. "There are five compelling reasons why I support this law," Sanchez said, right before he named the five victims of the Aug. 18 tragedy.
    "I'm really surprised at how people stigmatize mental illness still," says Robert, a researcher at UNM's Center on Alcohol, Substance Abuse and Addictions.

    Yet Robert adds that he supports mental health system reform—just not via Kendra's Law. "We need to go way farther beyond this," he says, adding that he believes councilors bowed to political pressure when it came time to vote on the ordinance. Robert concludes that if another shooting spree like this occurs in Albuquerque, "I'm afraid Chavez and his cronies are going to sit back and say, 'At least we tried.'"

    End of articles


     

     

     

     

     

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