General Resources / Legal Resources / Medical Resources / Briefing Papers / State Activity    
Hospital Closures / Preventable Tragedies / Press Room / Search Our Site / Home

Testimony

Testimony of Ron Honberg, J.D., M.Ed

Legal Director, National Alliance for the Mentally Ill (NAMI)

Arlington, Va.

Hearing on New York State’s Assisted Outpatient Treatment (AOT) Program

Thursday, April 21, 2005

Buffalo, NY

Assemblyman Rivera, Assemblyman Lentol, and distinguished members of the Committees.  My name is Ron Honberg and I am the Legal Director of the National Alliance for the Mentally Ill (NAMI). I am pleased to be here today representing NAMI, which is the nation’s leading organization advocating on behalf of people with severe mental illnesses.  Our members are primarily people living with severe mental illnesses and their families.   

For families, there is no more agonizing an experience than seeing a loved one with a severe mental illness deteriorate and being helpless to do anything about it.  Sometimes, appropriate mental health services may simply be unavailable.  Other times, the family member who is ill may refuse to utilize available services.  The consequences can be horrendous – hospitalizations, arrests and incarceration, homelessness, or even suicide. 

Since its enactment in 1999, Kendra’s law, which authorizes court ordered assisted outpatient treatment for certain individuals with severe mental illnesses, has enabled many people with severe mental illnesses throughout New York State to receive desperately needed treatment and supportive services.  Many people have made significant strides towards recovery and independence as a result of these services. 

Kendra’s law is scheduled to expire on June 30, 2005.  NAMI believes that Kendra’s law should be reauthorized and made permanent.  In support of this, I would like to briefly discuss three issues.

First, Kendra’s Law has helped the people it is intended to help.

Kendra’s law is based on the premise that, with appropriate treatment and supportive services, people with schizophrenia and other severe and persistent mental illnesses who have not been able to adhere to treatment regimens in the past will be able to recover and live productive, independent lives in the community.

Research and experience conclusively establish that appropriate treatment and  services – such as assertive community treatment, integrated mental health and substance abuse treatment, access to medications, and supportive housing – are very effective in facilitating recovery and preventing hospitalizations, arrests and other negative circumstances.  

Kendra’s law is designed to link people who meet the narrow criteria for AOT set forth in the law with these services.  And, the extensive evaluation of Kendra’s law that has been conducted by the New York State Office of Mental Health furnishes significant evidence that it is working.  Evaluation data collected after six months of participation in AOT showed marked improvements in individual day-to-day functioning, improvements in all areas of self-care and community functioning, reductions in harmful behaviors to self and others, and substantial declines in alcohol and substance abuse.      

Longer term findings are even more impressive.  Evaluation data collected at six month intervals over the entire course of AOT showed dramatic decreases in incidences of hospitalizations, homelessness, arrests and incarcerations.  Perhaps even more promising, hospitalization days continue to decrease significantly during the six month period following the termination of the court order.

Second, Kendra’s law strikes an appropriate balance between addressing the treatment needs of vulnerable individuals with severe mental illnesses and protecting their civil rights.                      

Mindful of the fundamental value placed on individual rights and personal liberties in American society, the New York State legislature, in enacting Kendra’s law, authorized the provision of AOT only under narrow circumstances.   At the same time, it is clear that Kendra’s law does not change the existing legal criteria under New York State law for the involuntary administration of psychiatric medications.   Kendra’s law merely authorizes the development of an assisted outpatient treatment plan for individuals who meet the criteria set forth in the law.  Based on the evaluation conducted by the OMH, it appears that these plans are successful in engaging individuals in treatment in most cases. 

In consideration of why AOT appears to be working despite the lack of an independent legal mechanism for compelling individuals to take their medications, at least three reasons may be considered. 

First, as a consequence of Kendra’s law and the resources that have been allocated to implement it, people under AOT are finally receiving the services they need.  And, once they receive these services and the severity of their psychiatric symptoms diminish, they will be more likely to continue participating in needed treatment and services.  This may be particularly true if the individuals under AOT experience these services in a positive, non-coercive way, as is suggested by the evaluation data provided by OMH.  

Second, Kendra’s law has stimulated the development of comprehensive services and service delivery systems that are effective in addressing the needs of people with severe mental illnesses.  Sadly, these services were frequently unavailable in many parts of the State. 

Third, Kendra’s law appears to create a powerful incentive for providers to serve people under AOT.  Previously, some of these providers may have been reluctant to serve people who meet the criteria for AOT, particularly those who have co-occurring mental illnesses and substance abuse disorders.          

Based on these arguments, some critics of the law assert that it is the heightened services, rather than the court order, that has produced the successful outcomes noted by OMH in its report.   However, while there is no doubt that comprehensive treatment and supportive services produce positive outcomes, NAMI believes that AOT court orders are necessary, as a last resort, to engage in treatment individuals whose symptoms repeatedly prevent them from acknowledging their mental illnesses and their need for treatment.

In some cases, schizophrenia and other severe mental illnesses may impair the ability of those who suffer from them to recognize that they are ill and in need of treatment.  For these individuals, the existence of a court order may serve as a powerful incentive to participate in services.  The “compulsion of law-abiding citizens to comply with court directives” was in fact noted by the Court of Appeals in its recent decision upholding the constitutionality of Kendra’s law.     And, the Court further noted that “any restriction on an assisted outpatient’s liberty interest felt as a result of the legal obligation to comply with an AOT order is far less onerous than the complete deprivation of freedom that might have been necessary if the patient were to be or remain involuntarily committed in lieu of being released on condition of compliance with treatment.”  

Third, the perception of coercion may ultimately be influenced more by one’s experience in treatment than in whether the treatment is provided under a court order.

The Institute of Medicine, in a recent landmark report entitled “Crossing the Quality Chasm”, developed a framework for measuring health care quality.   The four dimensions of this framework are:

• Patient-centeredness, the extent to which healthcare consumers are involved meaningfully in their own treatment;
• Safety;
• Effectiveness; and
• Timeliness

The first two of these dimensions are particularly important in the context of psychiatric treatment.  The sad reality is that people with severe mental illnesses have  typically not been meaningfully involved in their own treatment, or in decisions about their own treatment.  This has frequently led to treatment experiences that have been unpleasant at best and outright harmful at worst.  For example, many consumers I have spoken with talk of experiences where their efforts to communicate information about preferred medications and past experiences with side effects have been completely ignored by health professionals treating them in hospital settings.

Safety is another important factor.  Psychiatric treatment, particularly inpatient psychiatric treatment, has too often included excessive use of aversive measures such as seclusion and restraints as well as physical or sexual abuse by other patients or even staff.   These horrendous experiences understandably can drive consumers away from seeking help and treatment.

It is important to recognize that negative treatment experiences can occur irrespective of whether the treatment is “voluntary” or “involuntary”.  Voluntary treatment can be coercive if provided in a dehumanizing manner.  And, involuntary treatment can be surprisingly non-coercive if provided in a respectful, inclusive manner.

Preliminary results from face-to-face interviews conducted with AOT recipients by researchers at the New York State Psychiatric Institute provide promising indications that treatment experiences have been positive for many of these individuals.  The final report of the OMH on Kendra’s Law states that 62% of these individuals indicated that being court-ordered into treatment has “been a good thing for them.”  87% of the respondents indicated that they were confident in their case manager’s ability to help them, and 88% that they and their case manager are in agreement about what is important to work on.     

Kendra’s law emphasizes the importance of involving consumers, their families, and advocates meaningfully in treatment planning and in the implementation of the plan.  If implemented in this way, the experience of AOT may ultimately prove to be surprisingly “non-coercive” for service recipients.

Conclusion:

While many gaps still exist in the system of care for people with severe mental illnesses in New York State, Kendra’s law has been a positive step in engaging in treatment and services people who historically have been difficult to engage.  NAMI therefore strongly recommends that Kendra’s law be reauthorized and made permanent.  NAMI also recommends that the infastructure of services that has been established for AOT recipients be expanded and made available for individuals who are not under AOT.  The provision of quality, recovery-based services and supports for individuals with mental illnesses throughout the state will ultimately reduce expenditures associated with costly hospitalizations, incarceration, homeless shelters, and other “high-end” services.  

1. American Psychiatric Association, “Gold Award: Helping Mentally Ill People Break the Cycle of Jail and Homelessness—The Thresholds State, County Collaborative Linkage Project, Chicago”, Psychiatric Services, 2001 Oct; 52(10), 380-382.

New York State Office of Mental Health, Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment, March, 2005, pp. 10-16.

  Id  pp 17-19.

M.H.L. section 9.60(c)

  Rivers v. Katz, 67 N.Y. 2d 485 (1986).

  Kendra’s Law: Final Report, Id., pp 20-21.

Matter of K.L., 1 N.Y, 3d 362 (2004)

  Id.

ix. Institute of Medicine, “Envisioning the National Health Care Quality Report, Washington: National Academies Press, 2001.

   See, e.g., J. Monahan, M. Swartz, and R. Bonnie, “Mandated Treatment in the Community for People with Mental Disorders”, Health Affairs, September/October 2003, 2001.

FIND OUT MORE
Advocates page

general resources | legal resources | medical resources | briefing papers | state activity   
hospital closures | preventable tragedies | press room | search | home