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Testimony on Kendra's Law

Testimony of:

Marvin Swartz

Professor of Psychiatry

Duke University

Durham, NC

before the

Assembly Standing Committee on Mental Health, Mental Retardation and Developmental Disabilities

April 8, 2005

Good morning, Chairman Rivera, Chairman Lentol and members of the Assembly Standing Committees on Mental Health, Mental Retardation, and Developmental Disabilities,  the Committee on Codes and others in attendance. 

My name is Dr. Marvin Swartz and it’s a pleasure to have the opportunity to discuss Kendra’s Law with you this morning.  I am a Professor of Psychiatry at Duke University in Durham, NC, where, for over 15 years, we have conducted research on North Carolina’s version of assisted outpatient treatment (AOT) or involuntary outpatient commitment, as we refer to it in North Carolina. I am also psychiatrist and have treated persons with severe mental illness for nearly 25 years. We are very cognizant of the serious civil liberties concerns raised by AOT. As a result we try to conduct independent research that informs the public about how these laws affect treatment outcomes for consumers. Our research group is University-based and as independent investigators we have no advocacy position for or against AOT.

Our research group conducted the first randomized controlled trial of AOT and we were members of the research team who conducted the Bellevue AOT Study prior to enactment of Kendra’s Law. I am also a member of the MacArthur Foundation Research Network on Mandated Community Treatment which studies these laws and related public policies.

I would like to take a few moments to review what we have concluded about the effectiveness of laws such as Kendra’s Law and review some of the research that may be helpful in your deliberations about the future of Kendra’s Law in New York State.  I will not discuss the Bellevue Study because its findings will be discussed by others. It is our view that the Bellevue Study was conducted on too small a scale and too early in the development of the AOT program to be conclusive—if only because enforcement of AOT was not in place during the study.

Our research team has conducted a number of studies of the effectiveness of our version of AOT.  We have had the current version of the law since 1984. In our first experimental study, conducted in North Carolina, roughly 250 individuals with severe mental illness were randomly assigned to receive community mental health services with AOT or comparable community services without AOT.  Our objective was to study whether AOT provided any benefit over and above the benefit of consistent community services.  We studied severely mentally ill consumers for 12 months and interviewed consumers, their families and their clinicians to understand each person’s view of the effectiveness of AOT and what other benefits or detrimental effects a result of AOT. This is what we found:

• Consumers ordered to AOT had fewer readmissions to the hospital and spent fewer days in the hospital if they received AOT for 6 months or more and they were provided consistent and frequent community services during the commitment period. 
• We found that short periods of commitment (less than 6 months) –even if combined with frequent outpatient services -- provided no benefit.
• AOT, of any length, without consistent and frequent mental health services, provided no benefit.
• Bottomline: Only orders of 6 months or more combined with consistent and frequent services reduced rehospitalization.
• We also found that persons who received 6 months or more of AOT, combined with consistent and frequent mental health services, were less likely:
• To be violent,
• To be criminally victimized,
• Were more likely to comply with  recommended treatment -- including taking prescribed medication,
• Were less likely to be arrested if they had a history of arrests in the past,
• Were less likely to be homeless, and
• AOT combined with frequent services reduced the strain on families.
• We did also find that AOT came with some negative consequences that were of concern: Consumers under AOT did report feeling more coerced and pressured to comply with their treatment.  However, many consumers felt that AOT, on the whole, had improved the quality of their lives.
• Because AOT is so controversial, we wanted to get a better understanding of the opinions of different groups about AOT.  We wanted to understand how these groups view the tradeoffs between the benefits of AOT and the drawbacks of loss of liberty and potential stigma. 

To accomplish this we interviewed a randomly selected group of consumers with schizophrenia, family members of consumers with schizophrenia, clinicians treating consumers with schizophrenia and members of the general public.  We asked each set of stakeholders to rate the importance of concerns about the pros and cons of AOT.  In effect, the question we asked was “if AOT has the benefits of reducing hospitalization, reducing family strain, and reducing violence, is it worth it to trade-off the loss of liberty under AOT to gain these benefits?” 

To our surprise, each of these groups agreed that AOT was a reasonable price to pay to reduce hospitalizations, family strain and violence.  We then asked these consumers with schizophrenia whether they thought these types of legal policies were fair and effective.  Approximately two-thirds of these randomly selected consumers with schizophrenia believed that these types of policies, like AOT, were effective, and over half, 55%, thought that using these policies with mentally ill consumers was fair.  To be sure, consumers in New York may have different opinions about these policies and we may not have adequately studied consumers who have dropped out of treatment altogether.

• We next wanted to address the concerns voiced by a number of mental health advocacy groups that policies like AOT will scare consumers away from voluntary services for fear they will be placed under involuntary treatment.  In this same study, we asked the question whether a fear of involuntary treatment was a barrier to seeking services.  We did find that consumers believed that involuntary hospital treatment was a barrier to voluntary help-seeking—in effect scaring some consumers away from treatment. However, their primary concern was about involuntary hospitalization and consumers voiced few concerns about AOT—they did not feel laws like AOT would scare them away from seeking voluntary treatment. 
• We also conducted a random survey of over 500 clinicians --psychiatrists, psychologists and social workers in NC-- and asked them whether, in their experience, it was clinically realistic to do away with laws like AOT. The vast majority responded that laws like AOT were indeed needed for a small group of consumers to assist them in complying with treatment.
• Finally, the MacArthur Foundation Research Network on Mandated Community Treatment conducted a survey of over 1000 consumers in 5 cities to try to understand how common the use of AOT is in these cities and how consumers view these laws. We found that between 12-20% of consumers reported having received AOT or a related type of civil court order at some time in their lives.  The people who reported having AOT or similar court orders were the sort of people these laws are designed to help.  For example, these are people who had frequent hospitalizations, mental illness complicated by substance abuse, people with frequent encounters with police during mental health crises, and people with severe problems functioning in the community.  Nearly three-fourths of the individuals who had been on AOT also had encounters with the criminal justice system and other agencies where they had been required to accept treatment.  In this study, the majority of participants who had experienced AOT alone were satisfied with their treatment and felt less coerced compared with persons who had other types of treatment mandates such as criminal court ordered treatment.  That is, AOT appears to be less noxious compared to other means of forced treatment compliance. 

In summary, we think the question is not whether laws like Kendra’s Law are effective or not.  The question is: “under what conditions can laws like AOT be effective and at what personal costs?”  Our work suggests that AOT can be effective when provided for 6 months or more and combined with consistent and frequent outpatient services and come with what the consumers we studied consider acceptable personal costs.  Kendra’s Law is well aligned with research on how AOT can be effective - that is, by being applied over a reasonable length of time -- 6 months or more -- and by combining AOT with appropriate and frequent outpatient services. Our work suggests that you should continue to use AOT carefully, with the current legal safeguards and closely tie AOT to the assurance of appropriate services.

Thanks very much for the opportunity to speak with you today.

Marvin Swartz, M.D.

Professor of Psychiatry

Duke University Medical Center

Durham, N.C.

Email: [email protected]

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