In the ten years since Kendra Webdale was pushed to her death by a man who was denied services for his mental illness, discussions about what could have prevented this tragedy have occurred often. Led by New York State, more than 40 others passed laws mandating outpatient or involuntary commitment (AOT). But the issue is hardly resolved, evidenced by the activists, services providers, and psychiatrists who crowded the Columbia University law school to discuss what it means to "gain compliance in the community."

Perceptions of violence have driven coercive measures since Colonial times when jails and almshouses were filled by people with a mental disorder, said noted psychiatrist Dr. Paul Applebaum in a sweep of history. Prisons and hospital commitment are extremes, but other techniques such as money management or access to housing, along with Kendra's Law, are often used to leverage psychiatric treatment.

Despite evidence from major studies that such events are rare, in 1999 New York State passed Kendra's Law to promote public safety with forced outpatient treatment. New York said it was for people who were "unlikely to live safely in the community without supervision."

Many believe Kendra's Law and involuntary treatment is the emblem of a failed system, a common theme during a conference held at the Columbia University's law school last month where scholars, psychiatrists, activists, and service providers discussed AOT. There was almost no talk of violence, perhaps because the numbers are small. Most of the discussion pertained to services, those that exist and others that are still needed. Kendra's Law, said Dr. Marvin Swartz, one of the authors of a research study about its effect in New York, has actually been used most often for discharge planning. Still it remains controversial. And it is symbolic.

A system failure
When then-governor George Pataki signed the controversial law, critics said it was little more than a political response to a failed system of delivering mental health services. They needed to point no further than to the assailant. Goldstein had a record of attempting to get treatment, at least 11 times in just one year, but he had been sent away from community programs, discharged from hospitals without follow-up, unable to obtain medicines.

What if the law had been named after tragedy's other victim, and they called it the "System's Failure of Andrew Goldstein's Treatment Act," asked Sam Tsemberis. Would images and labels be diffferent? Tsemberis is the executive director of Pathways to Housing, an innovative program presuming adequate housing is the foundation, not the reward, of rehab.

New York's commissioner of mental health, Michael F. Hogan, inherited Kendra's Law when he was appointed by former governor Eliot Spitzer. Hogan headed the mental health offices of two other states, Ohio and Conn., before being named chair of the New Freedom Commission on Mental Health which made the principle of recovery indelible. While not directly critical of outpatient commitment, he said more attention is paid to the fewest people in a "famously fragmented" system. Hogan noted that less than half the people who have a serious mental illness get any kind of treatment, and much of the rise of reported services can be explained by a jump in prescriptions for Prozac.

Noting the lack of a coherent system, Hogan called for a new model to serve 98% of New York's adults with a mental illness, and move the discussion away from less than 2 percent of the state's adult population who fall under AOT services. Kendra's Law is set to expire in June 2010.

Newly added to MIWatch archives:
Sam Tsemberis discusses how AOT challenges treatment and consumer choice.