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The Story Behind Kendra’s Law
A 30-year-old man wrestles with schizophrenia for over a decade. He suffers visual and
auditory hallucinations. He is in and out of mental health facilities. He is involved in
six unrelated treatment programs in as many years. Repeatedly, he is released after a few
weeks of hospitalizations with nothing more than instructions to take his anti-psychotic
medicine.
Perhaps he tires of the side effects, feels he is well enough to do without the
medications, or doesn’t recognize he is ill at all. Whatever the reasons, he stops
taking the drugs that control the voices, irrational behavior, and delusions.
On his mother's birthday, January 3, 1999, and three weeks after he is released from a
22-day psychiatric hospital stay, he is standing next to a tall blond woman on a subway
platform. She firmly tells him to "back off". He approaches another woman and
asks her the time, and she replies.
A few moments later he grabs the woman around the shoulders and waist and throws her
into the path of an oncoming train. She doesn't have time to yell for help before she is
killed and dragged by the train.
Kendra Webdale is the victim in this incident. The 32-year-old record company
receptionist was also an aspiring screenwriter, recording artist, and freelance
photographer. She was 5'6" tall, 130 pounds, blond, vivacious, and in the wrong place
at the wrong time.
Andrew Goldstein is the young man charged with second-degree murder in the case. He was
found fit to stand trial and pled not guilty. If convicted, he faces 25 years to life in
prison. If found not guilty by reason of insanity, he will be sent to a mental facility
and kept until he is considered fit for release.
His trial began October 7, 1999, in Manhattan. In closing arguments, his attorney
called Goldstein the victim of a devastating disease and broken mental health system. A
3,500-page psychiatric history was offered in support of that claim. The attorney also
argued Goldstein’s psychosis made him incapable of understanding right from wrong.
The prosecuting attorney, however, argued Goldstein was using his mental illness as an
"excuse" to avoid responsibility for hurting people. Goldstein admitted to
killing Webdale and also claimed to have shoved or kicked other women during his time as
an outpatient. He claimed to have pulled a knife on one woman at a supermarket.
One confirmed incident resulted in a gash on a woman's head. In the outburst at a
Queens Barnes & Noble, Goldstein knocked a mother to the ground when her young child
apparently got on his nerves. The woman declined to press charges.
On November 2, 1999, its 6th day of deliberations, the Manhattan jury was unable to
reach a decision, forcing a mistrial. The jury of eight men and four women deadlocked 10
to 2 in favor of conviction.
Since Kendra's death, her family fought for better treatment of the mentally ill.
Kendra’s Law, signed August 9, 1999, brings assisted outpatient treatment to New
York. Similar laws are already in place in 40 other states. The New York law, dubbed
"Kendra's Law" after Kendra Webdale, passed in August.
Kendra's story is a highly sensational case. However, it and other highly publicized
cases helped raise awareness of the need for better treatment for the mentally ill. In one
similar incident just months after Kendra's, Edgar Rivera lost both his legs after being
pushed onto subway tracks. Police shot Charles Stevens eight times because he swung a
sword at passengers on the Long Island Railroad. Stevens lost the use of his arm as a
result of the shooting. His parents, Henry and Nadine Stevens, joined the Webdales and
Riveras in supporting the passage of Kendra’s Law.
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Kendra’s Law--The Culmination of a 10-Year Battle for Assisted Outpatient
Treatment in New York
by E. Fuller Torrey, M.D., President & Mary T. Zdanowicz, J.D., Executive Director
Before Governor Pataki signed the bill that became Kendra's Law on August 9, 1999, New
York was one of only 10 states without an assisted outpatient treatment law. Following on
the heels of a largely unsuccessful 10-year effort by advocates in New York to pass the
law, the Treatment Advocacy Center played a decisive role in making assisted outpatient
treatment available throughout the state. The history of this effort may be helpful to
others who would like to pursue similar reforms in their own states.
Assisted outpatient treatment was first proposed in New York in 1989 as a way to help
individuals with brain disorders who suffer because their illness prevents them from
accepting treatment. In 1994 the New York City chapter of NAMI convinced the New York
legislature of the need for assisted outpatient treatment. The legislature established a
watered-down, three-year pilot program, recognizing that "some mentally ill persons
frequently reject the care and treatment offered them on a voluntary basis and
decompensate to the point of requiring repeated psychiatric hospitalizations."
In July 1995, the pilot program began operating at Bellevue Hospital Center in New York
City. The program's director, Dr. Howard Telson, was largely responsible for its success.
Under the program, individuals who met the statutory criteria for assisted outpatient
treatment appeared before a judge to determine if they were eligible for court-ordered
outpatient commitment. As of January 1, 1999, 198 patients received court orders in the
pilot program.
The legislature also directed that a study be performed to determine the program's
effectiveness in preventing rehospitalization. Policy Research Associates, Inc. (PRA) was
selected to perform the research study despite concerns expressed by advocates about a
PRA's pre-existing prejudice against assisted outpatient treatment. The study began in
January 1996 and required that individuals in the pilot program consent to be included in
the study, which served to preclude individuals from the study who otherwise were good
candidates for assisted outpatient treatment.
PRA initially indicated that 150 subjects would be required for the research to have
statistical significance, but only 142 individuals participated in the study. The
experimental group of 78 individuals received court-ordered enhanced community services
while the control group of 64 individuals received enhanced community services, but no
court order.
PRA issued its final report (PRA Report) on December 4, 1998. PRA itself acknowledged
that the study was flawed, reporting that a "limit on [its] ability to draw
wide-ranging conclusions is the modest size of [the] study group." There have been
numerous studies of assisted outpatient treatment, all of which have concluded that
assisted outpatient treatment is effective with the exception of two studies, one of which
was the PRA study. However, in both studies there was no effective mechanism to enforce
the orders. During the entire PRA research study period, there was no procedure in place
to transport individuals who did not comply with treatment orders to the hospital for
evaluation. An enforcement mechanism was not put in place until shortly before PRA
published its report. In other words, non-adherence to a treatment order had no
consequences.
Despite those limitations, PRA's research suggests that the court orders did in fact
help reduce the need for hospitalization. Patients in the court-ordered group spent a
median of 43 days in the hospital during the study year, while patients in the control
group spent a median of 101 days in the hospital. PRA reported that, although not
statistically significant, there was a "big difference" between the experimental
and control groups. The difference, in fact, just misses statistical significance at the
level of p = 0.05.
The statutory authorization for the Bellevue pilot program was scheduled to expire June
30, 1999. The New York Treatment Advocacy Coalition (NYTAC) was formed in late 1998 to
mobilize support for both extending the pilot program and to make assisted outpatient
treatment available statewide. DJ Jaffe, Treatment Advocacy Center Board member and
long-time advocate for individuals with neurobiological disorders, is NYTAC’s
coordinator. Jonathan Stanley, Treatment Advocacy Center Assistant Director, serves as the
NYTAC liaison. DJ, Jon, and NYTAC members were tireless in their efforts.
A public hearing on the pilot program was held on December 13, 1998. The Treatment
Advocacy Center presented testimony in support of assisted outpatient treatment and
critical of the PRA Report. NYTAC members, family, consumers and other advocates also
testified in favor of the expansion of the pilot program. Opposition testimony, relying
heavily on the flawed PRA Report, was presented by primarily civil libertarians, some
community mental health providers, and consumer/survivor/ex-patients.
As the new year approached, it was not clear that New York legislators had the
political will to extend assisted outpatient treatment statewide, particularly in light of
the PRA Report. All of that changed on January 3, 1999, when Kendra Webdale, a beautiful,
vivacious, 32-year-old woman was pushed to her death in front of a New York subway train
by a man with untreated schizophrenia. Her family explained that, "Kendra was the
kind of person who would have tried to help the kind of person who pushed her."
Immediately following the incident, New York's newly elected Attorney General, Eliot
Spitzer, contacted the Treatment Advocacy Center. He was seeking a means of helping both
individuals with brain disorders and the communities where they live. The Treatment
Advocacy Center recommended that the Attorney General pursue passage of a comprehensive
assisted outpatient treatment law for New York. On January 28, 1999, the Attorney General
announced his proposal for statewide assisted outpatient treatment and acknowledged the
assistance provided by the Treatment Advocacy Center in crafting the bill.
The Treatment Advocacy Center also partnered with Kendra Webdale's family, who, as a
tribute to Kendra, were seeking a way to improve the quality of life for individuals who
suffer from severe mental illnesses and their communities. They enthusiastically supported
the bill and allowed it to be named "Kendra's Law."
As if Kendra's death was not enough to demonstrate the need for assisted treatment,
more tragedies soon followed. On April 6, 1999, Charles Stevens, a 37-year-old man with
untreated schizophrenia, wearing fatigues and wielding a sword, was shot eight times by
police on a Long Island Railroad train. Remarkably, he lived.
On April 28, 1999, Edgar Rivera, a 36-year-old father of three young children, was
pushed in front of a subway train by a man with untreated schizophrenia. Mr. Rivera lived,
but lost part of his legs. Mr. Rivera, like the Webdales, showed compassion for his
assailant. At the hospital he said "I have no legs, but at least I have my mind. This
guy doesn't have that. I think I'm ahead."
The Treatment Advocacy Center approached the Rivera and Stevens families and found that
they, too, enthusiastically supported Kendra's Law. Kendra Webdale's family, Charles
Stevens’ family, and Edgar Rivera and his family joined forces with NYTAC and the
Treatment Advocacy Center to advocate for Kendra's Law to ensure that New Yorkers most in
need of treatment for severe mental illness finally got it. The Center for the Community
Interest also plated a vital role in the campaign.
From then on, momentum for passage started building.
The families set out on meetings with newspaper editorial boards, reporters and
legislators. While support from the conservative media was expected, support from New
York's more liberal media was not. Major breakthroughs occurred when the New York Times
and Newsday, two liberal publications, joined conservative publications like the New York
Post and Daily News in support of Kendra's Law. In fact, New York's six largest newspapers
all enthusiastically supported Kendra's Law. The numerous letters written by NYTAC members
no doubt contributed to this success.
The Webdale family arranged meetings with Republican Governor George Pataki's counsel
and invited the Treatment Advocacy Center to attend. Following the meetings, Governor
Pataki joined the effort to pass Kendra's Law. Democratic Assembly Speaker Sheldon Silver
announced his support of Kendra's Law with Attorney General Spitzer in a press conference
on May 19, 1999, and invited the Stevens, the Webdales, and the Treatment Advocacy Center.
The same day, Governor Pataki introduced a slightly different version of Kendra's Law.
The slight differences in the bills provided an opportunity for opponents to try to
divide and conquer. A further complication was that the legislature became engaged in a
protracted battle over the state budget. However, the Treatment Advocacy Center, NYTAC
members, the Webdale, Stevens and Rivera families kept the pressure on and continued to
build its coalition. In June the New York State Association of Chiefs of Police passed a
Memorandum in Support of Kendra's Law.
The efforts culminated on August 3, 1999, when Treatment Advocacy Center staff, the
Webdales, and Mr. Rivera traveled to Albany to hold a press conference to beseech the
Governor and the legislature to enact Kendra's Law. Shortly before our press conference
was scheduled to begin, the Governor announced that a political agreement to pass Kendra's
law had been reached. One hour later, Governor Pataki and leaders of the State Senate and
Assembly held their own press conference announcing that they reached an agreement to pass
Kendra's Law. The bill subsequently passed the legislature by an overwhelming majority
(Senate 49-2/Assembly 142-4) and was signed into law on August 9, 1999.
The efforts to pass Kendra's Law shed light on the failures of the mental illness
treatment system in New York. As a result, Kendra's legacy is even more than bringing
assisted outpatient treatment to New York.
On November 9, 1999, Governor Pataki announced that he is halting the decades-old
failed deinstitutionalization policy in New York. The Governor proposed infusing an
additional $125 million in the budget for community-based services, of which $52 million
is earmarked for assertive community treatment, and $20 million will create 2,000 new
supervised housing units. This brings the Governor's total commitment for increased budget
allocations this year to $420 million for community treatment, supervised housing, and
implementation of Kendra's Law. The Governor is also suspending the push to eliminate
2,300 of New York's existing 6,000 inpatient psychiatric hospital beds (down from 96,664
beds in 1955).
It is sad that years of efforts by relentless mental health advocates like DJ Jaffe to
secure the benefits of assisted outpatient treatment for citizens with severe mental
illness had previously yielded such meager results. It is also discouraging that tragedies
and concerns about public safety became the catalysts to make Kendra's Law a reality.
However, it is a lesson about the importance of advocating outside the traditional mental
health arena and involving those with an interest in public safety and the victims of
untreated mental illness. The bill clearly would not have passed had it not been for
Attorney General Eliot Spitzer, the Webdales, the other families, the Center for the
Community Interest, and the Treatment Advocacy Center.
In the end, Kendra's Law will benefit individuals with severe mental illnesses because
treatment will finally be accessible to those who need it most. Achieving that goal is the
only hope of ending the senseless tragedies that make headlines; the ones that are
responsible for creating stigma against individuals with brain disorders. It is the first
real prospect of a better quality of life for individuals who are most ill with these
devastating diseases of the brain.
[Note: Visit (State Activity/NY) for a
copy of Kendra's Law and the Treatment Advocacy Center's summary, A Guide to Kendra's Law.]
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Half a Million Liberated from Institutions to Community Settings Without Provision for
Long-Term Care
by Curtis Flory MBA and Rose Marie Friedrich RN, MA
Deinstitutionalization has progressed since the mid-1950s. Although it has been
successful for many individuals, it has been a failure for others. Evidence of system
failure is apparent in the increase in homelessness (1), suicide (2), and acts of violence
among those with severe mental illness (3). Those for whom deinstitutionalization has
failed are increasingly re-admitted to hospitals. It is common to find persons who have
been hospitalized 20 times over a 10-year period. Tragically, there are more persons with
mental illness in jails and prisons than there are in state hospitals (4).
Beginning also in the 1950's, new treatment philosophies were introduced that
emphasized short-term and community-based treatments. Unfortunately, the wide range of
community support necessary to maintain persons with severe mental illness in the
community has not developed in many communities. In addition, the legal development of
"least restrictive" environment has frequently been interpreted as independent
living for all consumers, regardless of whether the setting is justifiable on clinical or
humanitarian grounds.
A comment from one frustrated mother clearly describes the plight of some who do not
find appropriate care in the community:
My son, who has schizophrenia, has been ill for 20 years. During his illness he has
been moved in the system 62 times, with 23 hospitalizations. He has been arrested numerous
times and has lived in shelters and on the street a minimum of 6 times. He has a substance
abuse problem and has been diagnosed with hepatitis and acute infections. We don't have
much hope for the future. (MA)
A Special High Risk Population
There is general agreement that about 2.8 percent of the U.S. adult population suffers
from severe mental illness during any given year (5). Among this population, there is a
subgroup of individuals who do not respond to traditional community treatment. It is
estimated that this high-risk population includes an estimated 1 million individuals, or
one-fifth of those with serious mental illness (6).
Unfortunately, discussion and research of this most vulnerable group has been
neglected, falling victim to the ideological war between pro-community integration and
pro-hospital camps. The most severely disabled have been forgotten not only by society,
but by most mental health advocates, policy experts, and care providers.
As co-directors of the National Alliance for the Mentally Ill (NAMI) Long-Term Care
Network, we conducted a study of this special population to determine their demographics,
treatment histories and quality of life. We developed a questionnaire that addressed
several areas of concern including housing, a variety of health issues, social and family
relationships, employment, finances, and safety.
Questionnaires were mailed to former members of the NAMI Hospital and Long-Term Care
Network and members of NAMI affiliates in Iowa and Massachusetts. Responses were received
from 500 families in 23 states. Most respondents were parents.
Issues related to housing and health are presented in this article. Commonly occurring
themes are presented along with family comments in these areas.
The majority of the following responses are from families who had an ill member
diagnosed with schizophrenia. In fact, 78 percent of the respondents reported that their
ill family member had the diagnosis of schizophrenia.
Frequent Transitions
- Clients resided in a wide range of settings and showed high frequency of movement, which
is symptomatic of fragmented care. The average client changed places of residence at least
14 times.
- Lack of adequate housing in the community was described by many. This lack of housing
option impeded returning to the community and opportunities for rehabilitation:
My son has been ready for about a year to come out of the hospital— but there is a
lack of 24-hour supervised housing—so he is still waiting for a placement. (MD)
He was in the state hospital for 6 1/2 years for his safety because he was a wanderer
and was unsafe. They kept saying there was no place for him in the community. (AZ)
- Lack of services resulted in total disability for clients and impacted every aspect of
their lives. On the average they had been ill for 21 years.
A parent from Alaska summed it up well, "It has caused (my son) to be totally
disabled. The combining of so many failures in treatment has left him with so many
residual problems that his potential for success . . . is minimal."
Medical Illness Was Pervasive
Medical illnesses frequently go undiagnosed and untreated among persons with severe
mental illness (7,8). The degree to which medical problems interfere with treatment and
rehabilitation efforts, and the danger that the presence of mental illness creates in the
management of medical disorders, have also been ignored in service planning. Furthermore,
clients are often unable to communicate their symptoms and give a coherent account because
of the internal chaos associated with their psychiatric illness and, therefore, the
illness may become severe before it is recognized and treated.
Medical problems may also result as a consequence of the poor health habits ofthis
population and/or the side effects of medications. For example, many persons with severe
mental illness are overweight, secondary to side effects of their medications, sedentary
lifestyle, and poor eating habits. This combined with heavy smoking leads to additional
cardiac risks. With proper monitoring and support services, these risks can be reduced.
- 48 percent of clients had medical problems.
- The most commonly cited medical diagnoses were arthritis, hypertension, and diabetes.
- Medical problems were frequently exacerbated by lack of a protective setting.
- Bad health habits and side effects of medications were commonly cited as contributing to
poor physical health.
Substance Abuse
Approximately 50 percent of people with a diagnosis of severe mental illness also have
a diagnosis of substance abuse disorder (2). Clients may self medicate because symptoms of
the illness are not under control or as a way to deal with their social isolation.
Consequences include noncompliance with medications, frequent rehospitalization, and
homelessness.
- 21 percent of clients had a substance abuse problem.
- Families related the occurrence of substance abuse to a variety of factors, including
lack of case management and social isolation.
Noncompliance was Common
Seventy-four percent of neuroleptic-responsive outpatients become noncompliant within
two years. The consequences of noncompliance account for at least 40 percent of all
episodes of schizophrenia relapse and for at least one-third of all inpatient costs (9).
The reasons clients do not take their medication are varied and may include lack of
insight, side-effects of medications, and inadequate structure and support within the
environment.
- 43 percent of clients had histories of noncompliance with medications, which led to
relapses in illness.
- Lack of insight into the illness was often associated with noncompliance. According to
one family member.
This is such a small space to describe 44 years of sheer hell. Most of my childhood she
refused medications. . . . The adult children had to commit her four times. . . . She was
delusional in New York City, Minneapolis, Tucson and she dug through garbage. It's always
up to the family to save her. (IA)
- Discharging the client prematurely from the hospital or removing the ill person from a
highly structured setting resulted in noncompliance.
- Inadequate staff and lack of follow-up also increased noncompliance.
- Noncompliance resulted in a progressively lower level of functioning.
Every time he has gone off medications he has never reached the level of capabilities
he had previously. (SD)
The Revolving Door Syndrome
The duration of stays in hospitals has become shorter under managed care standards.
Often clients are admitted and treated in hospitals before clients' records can be
transferred. Clients are often diverted from a familiar hospital to an available bed in
another hospital where staff are unfamiliar to the client. Stability and consistency is a
requirement of quality care for the severely mentally ill population.
- 75 percent of clients had been in the state psychiatric hospitals 1 to 50 times.
- 65 percent had been hospitalized in the acute care setting.
- The average number of acute care hospitalizations was seven.
- The impact of the revolving door syndrome was devastating.
Our son has cycled in and out of apartments and hospitals for 6 years getting
progressively worse. Lack of support services left him with his illness escalating beyond
control. (NC)
High Incidence of Suicide
Recent studies of persons with schizophrenia point out that about one-third will
attempt suicide, and about 1 in 10 will complete suicide. The suicide rate for those with
mood disorders is 15 percent. This is in contrast to the suicide rate for the general
population, which is 1 percent (2).
- 42 percent of clients had attempted suicide.
- Of those who attempted suicide, most had made two or more attempts.
- Families lived in constant fear of suicide.
We have constant fear that she will kill/hurt herself, sadness that she is so unhappy,
and have feelings of helplessness and guilt. (Has made 3 suicide attempts in the past).
(MA)
- Many of those in this subgroup are at high risk. They are primarily male, single,
unemployed, and often live alone. They also have chronic, relapsing illness, which
requires frequent hospitalization; have poor response to their medications, and feel
hopeless about their future.
- Suicide and attempts were attributed to lack of adequate services and medication
noncompliance.
Alarmingly High Death Rate
A fact that is seldom discussed but alarmingly true is that the death rate is
significantly higher for those who are severely mentally ill than it is for the general
population. It is clearly established that individuals with schizophrenia die at a younger
age than do individuals who don't have schizophrenia.
The largest single contributor to this statistic is suicide, which is 10 to 15 percent
as compared with 1 percent in the general population. Also contributing to early death are
poor health habits including heavy smoking, obesity, and alcohol abuse. The presence of
undiagnosed and untreated diseases, such as heart disease and diabetes, account for a
significant number of those who die young. Homelessness also increases the mortality rate
because of increased susceptibility to accidents and diseases (10).
Researchers and health professionals have long observed that psychiatric patients have
reduced life expectancy. In a study of 43,274 adults served by the Massachusetts
Department of Mental Health, Dembling et al. (11) found that this population lost 8.8 more
years of potential life than persons in the general population, a mean of 14.1 years for
men and 5.7 for women.
Structure is the Key Ingredient in Ideal Community-Based Residences
There is a need for both a structured and long-term care environment for this high-risk
population. According to H. Richard Lamb, structure is considered a "bad word"
in the treatment and rehabilitation of persons with severe mental illness compared to the
"good words" of independence and freedom. He states that although structure is
often considered a bad word, it represents a good and useful concept. Research indicates
that many persons with schizophrenia lack the ability to create their own internal
structure. If placed in the community in a living arrangement without sufficient structure
they may quickly decompensate and return to the hospital or to the streets (12).
In order to identify the important characteristics of structure, we surveyed NAMI
family members. Our questionnaire was published in many NAMI newsletters in Spring 1997.
Responses from 300 family members indicated that long-term care residences were
unavailable in a majority of communities.
Even if long-term care was unavailable, family members described the staff and services
that should be included in long-term care settings. Specifically, families identified that
onsite professional staff were very important. Approximately two-thirds of the respondents
considered it important that nurses and social workers be on site. About one-fifth wanted
physicians on site. Although onsite professional staff was identified as very important,
many felt it was not necessary for them to be in the setting full time.
Medication supervision was identified as the most important onsite service. Most (92
percent) said it was very important. Onsite recreational/social activities and meals were
also cited as very important by over three-fourths of the respondents. Learning job and
community living skills, while very important, may best be accommodated outside the living
situation according to family members (13).
The IMD Exclusion is a Major Barrier to the Availability of Long-Term Care
Size of the ideal setting is a critical factor, since onsite services tend to make
smaller group settings less economical. The typical cost per day for facilities in
Massachusetts and Iowa was $114 (9.7 beds mean) vs. $56 (31.7 beds mean) respectively. The
smaller facilities in Massachusetts did not have onsite professional services and programs
which were characteristic of the larger Iowa facilities (14).
The federal Medicaid exclusion of institutions of mental diseases (IMD exclusion) is a
major barrier to the development of long-term care facilities with adequate structure and
support services for individuals suffering from severe mental illnesses.
The IMD exclusion prohibits Medicaid reimbursement for institutions with more than 16
beds, that are primarily engaged in providing diagnosis, treatment, or care of persons
with mental diseases (15). This law has become a major barrier to the availability of
economical long-term settings, which can provide structure and professional supervision,
and should be eliminated.
Endnotes for "Half a Million Liberated from Institutions."
1. E.F. Torrey, Nowhere to go: The Tragic Odyssey of the Homeless Mentally Ill. New
York: Harper and Row, 1988.
2. N.C. Andreasen, DW Black: Introductory Textbook of Psychiatry. Washington, DC:
American Psychiatric Press, Inc., 1995.
3. Dixon, LB, JM Deveau: Dual diagnosis; the double challenge, NAMI Advocate 20, 16-17:
NAMI, Arlington, VA, April/May 1999.
4. Torrey, EF, J Stieber, J Ezekial, et al: Criminalizing the Seriously Mentally Ill:
The Abuse of Jails as Mental Hospitals. Washington, DC, National Alliance for the Mentally
Ill and Public Citizen’s Health Research Group, 1992.
5. Health care reform for Americans with severe mental illness: Report of the National
Advisory Mental Health Council, American Journal of Psychiatry 150, 1993, at 1447-1465.
6. R.M. Friedrich, C.B. Flory, Hope for those who require long-term care? NAMI Advocate
17: NAMI, Arlington, VA, 1997, at 13-14.
7. National Institute of Mental Health, Caring for People with Severe Mental Disorders:
A National Plan of Research to Improve Services. DDHS Pub. No. (ADM) 91-1762, 1991, at
1762.
8. B. Felker, J.J. Yazel, D. Short, Mortality and medical comorbidity among psychiatric
patients: a review, Psychiatric Services 47, 1996, at 1356-1363.
9. P. Weiden, Medication noncompliance in schizophrenia: A public health problem, The
Decade of the Brain 4, 1993, at 5-8.
10. Torrey, E.F.: Surviving Schizophrenia: A Manual for Families, Consumers and
Providers. New York: Harper & Row, 1995.
11. B.P. Dembling, D.T. Chen, L. Vachon, Life expectancy and causes of death in a
population treated for serious mental illness, Psychiatric Services 50, 1991, at
1036-1048.
12. H.R. Lamb, Structure: the unspoken word in community treatment, Psychiatric
Services 46, 1995, at 647.
13. R.M. Friedrich, C.B. Flory, Structure is the key ingredient in ideal community
based services, AMI of Iowa Newsletter, Fall 1997, at 14-15.
14. R.M. Friedrich, C.B. Flory, H.B. Friedrich, C.G. Hudson, A survey of community
residences for persons with severe mental illnesses (manuscript in progress).
15. 42 U.S.C. � 1396d(I).
