The secret history of mandated treatment

Mandated treatment is about society’s needs, not the mentally ills’.

On the evening of January 3, 1999 Kendra Webdale stepped onto the platform of the uptown R train at the West 23rd St station in Manhattan. She was 32, blonde and had a reputation for being kind to a fault, so it must have been typical for her to exchange words with the man beside her.

image
Kendra Webdale

Then the man pushed her in front of an oncoming train, decapitating Webdale.

The man, Andrew Goldstein, had a history of hospitalizations for schizophrenia. When asked why he killed Webdale he later said he “just had the urge to push her.”

image
Andrew Goldstein

In response to what he did that evening state lawmakers would pass Kendra’s Law, far-reaching legislation that lets judges mandate mental health treatment. But like any ambitious mental health program Kendra’s Law says as much about society’s fears as it does the needs of the mentally ill.

To understand what mandated treatment is really about, we need to understand those fears.

Kendra’s Law is a marketing tool designed to assure affluent white people that the problem of dangerous, crazed loners is under control.

Kendra’s Law is sweeping. It lets judges require people to submit to mandated treatment for up to a year at a time if they’re judged not to be safe without supervision and establishes teams of workers to provide services and monitor compliance. Though often justified with the rhetoric of public safety, a person doesn’t need to have a history of violence to be mandated under the law.

The law was used more than 8,700 times by mid-2007, with more then 5,600 of those people seeing their mandated services extended. Most people affected by the law (70%) are in New York City; many upstate counties don’t use the law at all.

That’s the law. Understanding the law’s purpose requires knowing a bit about New York – and Kendra Webdale herself.

Webdale was in many ways the prototypical New Yorker. An aspiring screenwriter from Fredonia, NY, she was drawn to the city by its parks and museums.

She wasn’t the first person to die on the subway tracks. Subway crime was down in 1999, but according to the New York Post, “even in safe times, a common fear haunt[ed] riders standing on a crowded platform. It’s of being shoved in front of a speeding train by a crazed attacker.” People remembered Renee Katz, who lost a hand in a similar attack, and several other people not named in the article (a 63-year-old grandmother, a Staten Island chemist, a 20-year-old mother described as having “cheap costume jewelry”).

Why did Webdale’s death merit a response from then-mayor Rudy Giuliani and eventually lead to a landmark state law while these other victims have been forgotten?

The numbers tell the story – a story of race, money and politics.

In the 1970s New York City was in trouble. Plagued by crime and a bad economy, white people and families fled in record numbers, to the point where whites were nearly a minority group. In the 1980s the population started to rebound, but the increase was driven by immigrants, who made up for a continuing exodus of white people. Crime was still rampant, and
the city’s image was reflected in the unstable loner Travis Bickle, Robert Dinero’s character in Taxi Driver. It wasn’t until the 1990s, the decade that Webdale moved to New York, that the city’s population really began to take off, growing by nearly 1%. By now the bleak image painted by Taxi Driver was being supplanted by Seinfeld and Friends – images of a kinder, more liveable city.

image
I love New York!

However, crime still scared both current and potential New Yorkers. And even then a quarter of the city lived in poverty, up from previous years.

When a white woman who moved to the city in pursuit of her dreams was murdered by an unstable New Yorker, then, it must have been the worst publicity imaginable for city leaders.

They sprang into action.

After Webdale’s death Elliot Spitzer, then state attorney general and a city native, proposed legislation requiring mandated treatment, and the New York Times editorialized that such a law would be good for both people with mental illness and the city as a whole. Powerful New York State Assembly Speaker Sheldon Silver, who represented a Manhattan district, introduced the bill that would become known as Kendra’s Law. Silver was clear that “the specific incident that inspired ‘Kendra’s Law’ accurately depicts this as a public safety issue” while noting that his bill would also benefit those with mental illness.

Kendra’s Law passed. But like other public safety initiatives it wasn’t applied evenly.

In 2005 New York Lawyers for the Public Interest condemned Kendra’s Law, stating that only 15% of people mandated to treatment under its provisions had a history of violence. NYLPI accused those implementing the law of bias – citing figures from the New York State government, they said black people were nearly five times more likely than whites to be subjected to Kendra’s Law orders (others would say this is because black people are less likely to receive appropriate treatment). They also noted a regional bias, stating New York City accounted for 76% of orders despite having only 42% of the state’s population – exactly what one would expect if the law was created to make the city seem safer.

The marketing seems to have worked. By 2007 the number of people moving to New York City from other parts of the country surpassed the number leaving, a “new pattern,” and immigrants from within the United States went from representing half of the inflow at the turn of the millenium to two-thirds by 2011. Incomes rose too, with the median household income going from $31,591 in 1990 to $54,310 in 2014 when adjusted for inflation.

New York City became wealthier, whiter and more appealing to people from other states after Kendra’s Law passed. The law wasn’t solely responsible, of course, but it was one of the policies that made the New York success story possible.

What does this all mean? Many conclusions can be drawn. Here’s mine: Kendra’s Law is a marketing tool designed to assure affluent white people – inside and outside of the city – that the problem of dangerous, crazed loners is under control. When a mentally ill man murdered an attractive white woman from the suburbs city leaders feared Taxi Driver New York was killing Friends New York. They sprang into action, successfully lobbying for a law that’s used almost exclusively against poor black city residents.

None of this is to deny that Kendra’s Law has been effective. Studies by Duke University and the New York State Office of Mental Health have found the law reduces hospitalizations as well as suicide attempts, homelessness and other problems associated with untreated mental illness. Supporters of the law say it’s helping people who are mandated to services and saving the city money by reducing the need for inpatient care.

Mandated treatment is clearly a complicated issue that defies easy answers. But when we debate its wisdom we should consider all of its pros and cons, including some that are often overlooked by its supporters.

For example, any discussion of Kendra’s Law should consider:

The increased burden on mental health clinics that are required to treat mandated clients;

The impact of stringent rules clinics impose to manage mandated clients, such as policies to drop clients if they miss appointments;

The waiting lists clinics create to accommodate increases in demand;

The potential clients who give up on counseling because they’ve been placed on waiting lists;

The stress experienced by therapists and social workers who must work with mandated clients;

The impact this stress has on their work;

The good things providers could be doing with voluntary clients but aren’t because they’re working with mandated clients instead;

The things that could be done with money currently spent on mandated clients;

The pain clients experience after losing autonomy.

I’ve worked in agencies that serve mandated clients and I can truly say their being mandated changes everything. They stop being clients at all; instead they are treated like difficult, ungrateful children. When a clinician constantly assumes an unwilling client won’t show up or won’t be interested in material, it’s hard to overestimate the damage that causes to the therapeutic relationship. In a 2009 study of Kendra’s Law, case managers rated 54% of participants as not being “positively engaged” a full year after services began.

The above points demonstrate an odd fact: while Kendra’s Law has made treatment more available for mandated clients, the result has been that treatment has become more scarce for voluntary clients – the ones who are most likely to benefit from treatment. Every time a client is mandated waiting lists grow longer, clinicians become less available and clinic policies become more rigid. NYLPI says that this “right to treatment” for mandated clients even leads some people who want treatment to intentionally become mandated so they can get the help they need.

A stunning 41% of New Yorkers with severe mental illnesses report they needed help in the past year but weren’t able to get it. Does that mean we should have more mandated treatment? Maybe – but this treatment gap makes me question the wisdom of forcing scarce mental health resources on those who don’t want it.

I don’t know whether Kendra’s Law should be changed or repealed. But let’s be real about our reasons for mandating treatment. Let’s own the harm and benefits of it – all considerable and all very real.

In other words, let’s honor Kendra Webdale, Andrew Goldstein and the 20 year old mother in costume jewelry the New York Post didn’t bother to name.