Politics & Policy

How a 1999 Subway Pushing Changed the Nation’s Mental-Health System

States can keep the public, patients, and police safer while saving money for taxpayers.

Earlier this month, Andrew Goldstein was released from Sing Sing Correctional Facility in Ossining, N.Y. He’d spent 19 years behind bars for pushing Kendra Webdale to her death in front of a subway train during a period when his schizophrenia was not being treated.

Kendra lost her life, Andrew lost his freedom, and commuters learned to stand back from the subway tracks. But a law that came out of Kendra Webdale’s tragedy taught states how they can keep the public, patients, and police safer while saving money for taxpayers.

The law is technically known as assisted outpatient treatment (AOT). In New York it was named after Ms. Webdale and called Kendra’s Law. The notoriety of her pushing, combined with the well-researched and inarguable success of the program in New York, caused at least nine other states to make changes to their own AOT laws or enact them if they didn’t have one.

These laws were also named after victims. Kentucky enacted “Tim’s Law,” California enacted “Laura’s Law,” New Jersey enacted “Gregory’s Law,” and on it goes. While 47 states now have AOT — Connecticut, Maryland, and Massachusetts being the exceptions — no state makes sufficient use of it. They should.

Assisted outpatient treatment is the practice of delivering outpatient treatment under court order to a small, highly targeted population: adults with serious mental illnesses such as schizophrenia and bipolar disorder who meet specific criteria, such as repeated past hospitalizations, violence, or arrests due to their failure to comply with treatment. AOT allows judges to require these individuals to stay in closely monitored treatment for up to a year, while they continue to live in the community.

Mandated and monitored treatment has been a huge success. Studies in New York, Los Angeles, North Carolina, Arizona, and Iowa show that AOT increased treatment compliance or lowered the number of days spent homeless or hospitalized or incarcerated in the 70 percent range, an outstanding result since only the most seriously mentally ill are eligible.

By using mandated treatment in the community as an alternative to expensive involuntary hospitalization and incarceration, AOT saves taxpayers 50 percent of the cost of care. Incarcerating Mr. Goldstein is estimated to have cost taxpayers $1.2 million. Kendra’s Law, comparatively, costs about $60,000 per year — much of which is Medicaid-reimbursable while providing a faster path to recovery.

Ninety percent of those in the program, who it might be assumed would object to being compelled to accept treatment, say it helps them get well and stay well. AOT has robust support among parents of the seriously mentally ill and criminal-justice professionals. Since Kendra’s death, the International Association of Chiefs of Police, the National Sheriff’s Association, Department of Justice, the Substance Abuse and Mental Health Services Administration, and the American Psychiatric Association have all come out in support.

So why isn’t AOT used more often? AOT sends the most seriously ill to the head of the line for services, and many mental trade associations don’t want them there. They want government funds, but not an obligation to treat the most seriously ill, who can be the most difficult to treat. Some vocal opponents argue that experiencing delusions is merely an “alternative reality” conferring a right to be protected, rather than an illness to be treated. They claim AOT violates rights. But courts say they are wrong. AOT enables patients to avoid inpatient commitment and incarceration, thereby maintaining more of their civil liberties. Opponents also argue that if more voluntary services were available, we wouldn’t need to compel people into treatment. But most AOT laws are limited to those who are unlikely to voluntarily participate in treatment. Offering more services to people who reject them will not help.

Assistant Secretary of Mental Health and Substance Use Disorders Elinore McCance-Katz is working hard to expand the use of assisted outpatient treatment, but Congress and the president need to give her more funds specifically for the mission. There are plenty of useless pop-psychology programs that could and should be cut to fund it. The public must demand that state officials expend mental-health dollars on those who need help the most, not the least, and on lowering rates of homelessness, arrest, incarceration, needless hospitalization, and violence. That means insisting their states make greater use of AOT even if that displeases mental-health trade associations that don’t want to accept the seriously ill.

Andrew Goldstein knows it would have helped him avoid incarceration. He recently told the Marshall Project about the law: “You know, it’s a really good law — not like some totalitarian law where they could just throw you in a mental hospital. They have legal requirements, a hearing . . .” A silver lining he sees in his tragic act.

If he recognizes the sanity of this approach, why can’t the rest of us? We know how to fix the mental-health system. What’s lacking is leadership.



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