The Truth About Kendra's Law: Let's Make Policy Based on Facts Not Fear PDF Print E-mail

 

Mental Health E-News; February 8, 2006

Advocates Urge New Mexico Legisature to Reject Kendra's Law Proposal

 

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

MYTH 
Many with serious mental illnesses are just too sick to get well, will never work, marry or have good

judgment and will always need custodial forms of care like Kendra's Law that direct their care for them. 

FACT
Individuals with even the most severe psychiatric disabilities can achieve significant levels of recovery, when

 they are offered the choice of the right kind and mix of modern services and medications.

 


EVIDENCE
1997 Maine-Vermont Comparison Study per British Journal of Psychiatry Dr Courtenay Harding

 et al
http://akmhcweb.org/ncarticles/Vocational%20Rehab.htm

MYTH
People with serious mental illnesses typically refuse good services

FACT
Despite research indicating highly successful service and medication models of care, most people still are not offered or can't get access to the right mix of the right services.

EVIDENCE
1998 Patient Outcomes Research Team (PORT) Study, Agency for Health Care Policy and Research (AHCPR) and the National Institute of Mental Health (NIMH): 'Fewer than Half of Schizophrenia Patients Get Proper Treatment'   http://www.ahrq.gov/news/press/schizpr4.htm

MYTH
The individual who pushed Kendra Webdale to her tragic death (Andrew Goldstein) refused care and required forced outpatient treatment.

  

FACT 
Andrew Goldstein repeatedly sought care which nonetheless failed to adequately respond to help him.

 


EVIDENCE
1999 NYS Commission on Quality of Care for the Mentally Disabled review
"This fragmented series of services was insufficient to meet the complex needs of Mr. (Goldstein) and to protect those around him." "As indicated in the findings, Mr. (Goldstein) would often present himself for treatment, complaining that he was anxious, hearing voices and unable to control himself, and ask to be helped, at times requesting supervised housing."

MYTH
People with serious mental illnesses won't take their medications because they have a "brain deficit that renders them unable to perceive that they are ill." Proponents have even come up with a name for this new condition they have come up with, "anosognosia." Psychiatric News   September 7, 2001

FACT
A recent study found that 75% go off meds because they don't find that those medications works or because of disturbing side effects 

EVIDENCE
2005 National Institute of Mental Health 'CATIE' study: A large (1,400 patients) study that provides, "for the first time, detailed information comparing the effectiveness and side effects of five medications &. that are currently used to treat people with schizophrenia. Overall, the medications were...associated with high rates (75%) of discontinuation due to intolerable side effects or failure to adequately control  symptoms."

  http://www.nimh.nih.gov/healthinformation/catie.cfm

MYTH
People with serious mental illnesses are dangerous and pose a major threat to public safety.

 


FACT
People with serious mental illnesses are no more violent than the general public and are far more likely to be victims of violence.

EVIDENCE
-1998 McArthur Study on 'Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods'   Steadman et al 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."

http://archpsyc.ama-assn.org/cgi/content/abstract/55/5/393?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Steadman&searchid=1139212828284_30&FIRSTINDEX=0&journalcode=archpsyc

-2005 "Crime Victimization in Adults With Severe Mental Illness" study   Teplin et al Archives of General Psychiatry. "More than one quarter of persons with SMI had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population rates."

 
http://archpsyc.ama-assn.org/cgi/content/abstract/62/8/911

-Violence and the Mentally Ill   Victims, Not Perpetrators   Arch Gen Psychiatry. 2005;62:825-826. 
http://archpsyc.ama-assn.org/cgi/content/extract/62/8/825?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Steadman&searchid=1139212828284_30&FIRSTINDEX=0&journalcode=archpsyc

MYTH
Forced outpatient treatment measures are needed to achieve better results with "at risk" groups.

 


FACT
Better services, and not court mandates, work best.

EVIDENCE
-2001 "Assessing the New York City Involuntary Outpatient Commitment Pilot Program" Steadman et al  Psychiatric Services  A three-year study at Bellevue Hospital of a program similar to one later mandated by Kendra's Law, compared the impact of providing an enhanced, better-coordinated package of services both with and without the use of a court order. Results: "On all major outcome measures, no statistically significant differences were found between the two groups" yielding the conclusion that people do better when they are offered better services, not because they are forced to accept them. 

 http://ps.psychiatryonline.org/cgi/content/short/52/3/330

-2001 Rand study
Proponents of Kendra's Law like to dismiss the Bellevue study's findings and to cite a Duke University they believe found involuntary outpatient commitment an effective intervention. Yet, a 2001 prestigious Rand study concluded that "the Duke study does not prove that treatment works better in the presence of coercion or that treatment will not work in the absence of coercion."

http://www.rand.org/pubs/research_briefs/RB4537/index1.html

-2005  "Compulsory community and involuntary outpatient treatment for people with serious mental disorders"  Kisely et al  The Cochrane Library  
"It appears that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. There is currently no evidence of cost effectiveness."

MYTH
The forced outpatient mechanism in New York's Kendra's Law is responsible for  the good outcomes reported in a recent evaluation conducted by the NYS Office of Mental Health.

FACT
The OMH research design was flawed in that, unlike the Bellevue study and other scientific evaluations, it has no comparative "control" group and, hence, can't prove that the improved outcomes were not due to New York's recent advances in services access, funding, coordination & accountability, rather than to the forced outpatient treatment mechanism.

EVIDENCE
2005 Report "Implementation of 'Kendra's Law' Is Severely Biased" New York Lawyers for the Public Interest  "While it claims many apparent benefits for those subjected to court orders, it is impossible to tell from OMH's data what is accomplished by compulsion and what by enhanced access to services." The OMH research is based almost entirely on the opinions of case managers and, unlike the Bellevue Study, fails to provide a comparison with a control group of those who received a voluntary package of similarly improved, well-coordinated services, including housing and case management. 
http://www.nylpi.org/pub/Kendras_Law_04-07-05.pdf

MYTH
Only force can work for some groups

FACT
Good voluntary services get very good outcomes with same population as Kendra

EVIDENCE
-2000 "Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals With Psychiatric Disabilities" Psychiatric Services Tsemberis and Eisenberg 
An innovative "harm reduction" housing and support program model was able to achieve an 88% service retention rate and general stability among a group of primarily young men of color with psychotic disorders and previous histories of homelessness and non-participation with services&the very same group of those who have been "incapable of living and maintaining treatment in the community" that Kendra's Law proponents would have us believe can only be served via court order. And he does this without mandating treatment adherence or abstinence but by offering 'housing first' via a model that merges supported housing and ACT team services.
http://ps.psychiatryonline.org/cgi/content/abstract/51/4/487

-Shelly Nortz, Coalition for the Homeless, 2005 NYS Assembly Public Hearing
An innovative voluntary community housing initiative, 'New York/New York,' has achieved an 88% compliance level and an average 83% reduction in re-hospitalization, incarceration and homelessness for over 10,000 homeless seriously mentally ill adults, rivaling if not exceeding corresponding rates for those ordered into treatment under Kendra's Law.

-2003 "Public Service Reductions Associated with Placement of Homeless Person with Severe Mental Illness in Supportive Housing" Culhane et al  Housing Policy Debate 
The study by Penn Center for Mental Health Policy and Services Research concludes that, on average, the homeless mentally ill use $40,500 a year in public funds for shelter, jail and hospital services. But providing them with supportive housing would cost the same amount while also providing them with comprehensive health support and employment services.
http://www.upenn.edu/pennnews/article.php?id=376

MYTH
Forced treatment measures get potentially violent individuals into care.

FACT
In truth, the Kendra's Law mandate program is used by counties, families and even the patients to "get to the front of the line" and gain access to preciously scant local service systems and housing. Why can't we develop 'right to treatment' mechanisms for at risk individuals to make sure that they get into services they need...and make sure we fund enough services to make sure that others aren't pushed to the bottom of the list to make room for them?

EVIDENCE
John Gresham, New York Lawyers for the Public Interest: "Most court orders have been used to link nonviolent individuals with priority access to scant services. Must we rely on courts and cops to make our system more responsive and more accountable? Localities that are turning to court orders are using them primarily to get individuals with 'high needs' to the 'front of the line' for scarce services and housing. Only 15 percent of those under court orders have done any physical harm

MYTH
Court ordered care under Kendra's Law has had a major statewide impact.

FACT
Court orders have been concentrated in 8 counties and New York City, with the remaining 49 counties using few to none.

EVIDENCE
-Nassau County Mental Health Commissioner Howard Sovronsky: "We must not lose sight of the fact that it is largely the availability and access to community-based services that has the greatest impact on our most needy citizens. It is the support and encouragement we provide that is the most valuable aid. It is compassion not coercion that must drive our system." (NYS Assembly Public Hearing).

-Harvey Rosenthal, NYAPRS  2005 Assembly Hearing: "Once you take out New York City's 3,000+ court orders (which represent over of all court orders statewide), most counties have been far more successful in engaging individuals with serious psychiatric conditions without the use of forced treatment. For example, 13 counties have not produced even 1 court order; 12 counties have produced 2 or less forced treatment orders: Also, NYC has sought court orders for 3 out of every 5 investigations; in contrast, Onondaga Co. (Syracuse), has only sought court order for 1 out of every 12."

MYTH
Most advocates support forced outpatient treatment measures.


FACT
Most NYS mental health advocacy groups in NYS opposed the passage of Kendra's Law in 2000. Nationally, many leading mental health advocacy groups oppose forced outpatient treatment, most notably the National Mental Health Association (http://www.nmha.org/shcr/ioc_factsheet.cfm  and the United States Psychiatric Rehabilitation Association (http://www.uspra.org/files/public/commitmentPos.pdf).

MYTH
The NYS legislature strongly supports Kendra's Law.  


FACT
"In 2005, the NYS Legislature was so troubled by the program, by its questionable research and by a host of unanswered questions about the program's implementation...that it refused to relinquish its oversight role, refused to make it permanent, rejected efforts to expand the use of forced outpatient treatment and at the same time, required that an independent body conduct a more trustworthy evaluation."   NYAPRS news release

CONCLUSION
...In our understandable grief and fear, we must not rush to embrace the false beliefs that forced outpatient treatment programs will prevent violence. The research shows that good services that are adequately funded, accessible, coordinated and accountable will best help reduce tragic incidents. 
Let's instead devote ourselves to committing the state's political will, wisdom and funding....and committing our state and local governments and community providers to provide the range of services that science tells us will surely engage those most in need, even those at risk of coming to and/or causing harm.... before we talk about committing innocent non-violent individuals to forced outpatient treatment orders.

 

Harvey Rosenthal, New York Association of Psychiatric Rehabilitation Services
February 8, 2006