Independent Evaluation Finds No Benefit to Coercion Under New York’s Kendra’s Law

Kendra’s Law is a New York State statute that allows courts to force people with “severe mental illness” into involuntary Assisted Outpatient Treatment (AOT). People with an AOT order are monitored by the state and live under the threat of psychiatric detention for non-compliance. As of 2024, 48 states as well as Washington D.C. have laws that allow for involuntary court ordered AOT.

A new independent evaluation of New York State’s AOT program finds that AOT mandated by court order had no benefit over voluntary psychiatric treatment programs. This independent report, undertaken by the Human Services Research Institute and the University of Pittsburgh, also finds that court mandated AOT exposed involuntary patients to coercion and lack of agency, with compliance often based on fear of sanctions and psychiatric detention. The authors write:

Luke Sikinyi, the vice president of public policy for the Alliance for Rights and Recovery said of the recent report:

Harms Linked to AOT

Past research has repeatedly found that AOT and similar community treatment orders provide no benefits to involuntary patients while exposing them to the harms associated with psychiatric coercion. A 2020 UN report said that “involuntary psychiatric interventions based on ‘medical necessity’ or ‘best interests’ may well amount to torture.” According to data published by the New York State Office of Health, court mandated AOT disproportionately affects minorities and people living in poverty.

In making their case against AOT, Robert Whitaker and Michael Simonson highlight the role of AOT in the suicide of Andrew Rich and argue that AOT proponents have sold the public on the merits of these programs by ignoring the numerous studies that point to the failure of this paradigm of care. Research has linked these programs to patient distress, isolation, trauma, loss of autonomy, a breakdown of the therapeutic alliance and loss of trust in the mental healthcare system.

AOT also exposes involuntary patients to the harms of psychiatric drugs. According to data from 2024, 99% of people living under an AOT court order in New York had psychiatric drugs as part of their treatment plan with 86% receiving long-acting injectable antipsychotics. While technically “medication over objection” is not legal in AOT, it is important to remember that many involuntary patients comply with AOT due to fear of psychiatric detention.

Past research has found that antipsychotic drugs provide no clinically meaningful benefit in the short-term. Numerous studies have also reported that antipsychotics lead to worse long-term outcomes. One study found that recovery was six times more likely for people that stopped taking antipsychotics within 2 years. These drugs have been linked to increased risk of suicide, early death, brain damage, poor heart health, reduced cognitive function, tardive dyskinesia, and dementia. Service users and patients have reported numerous negative effects linked to antipsychotics, including emotional numbness, weight gain, identity issues, and stigma related to taking these drugs.

The Independent Evaluation of New York State Assisted Outpatient Treatment

The aims of the current work were to examine the outcomes of AOT, coercion related to AOT, and to determine whether improvements to patients were the result of the court ordered psychiatric treatment or the greater access to services that accompany the court order.

The authors used a mixed methods approach that included both quantitative administrative data, a survey of AOT administrators, and qualitative interviews with people under an AOT order, family members, and key system actors including judges, psychiatrists, and legal representatives.

The authors used administrative data to evaluate key outcomes including hospitalization, arrests, service engagement, housing stability, and safety. For the purposes of analysis, people under court mandated involuntary AOT orders were compared to those that were receiving voluntary Assertive Community Treatment (ACT). In total, the authors analyzed quantitative data from 11,553 people that received court mandated involuntary AOT and 8,369 service users receiving voluntary treatment through ACT.

The authors also analyzed interviews with 244 people including 46 people under AOT orders, 25 family members, and 173 system actors. They coded the interview data for common themes and lived experience perspectives. In addition to human coding, the interview data was also run through systematic AI-assisted thematic analysis.

Of the 10 outcome measures observed in the current work, four had better outcomes in the involuntary AOT cohort: housing status, risk of harm to others, at least one mental health hospitalization, and number of mental health inpatient nights among those with at least one mental health hospitalization. Two outcomes were better among the voluntary ACT cohort: at least one arrest and number of arrests among those with at least one arrest. All 10 outcome measures improved for those in the ACT group while nine of 10 improved in the AOT group. The authors note that those in the voluntary ACT cohort also had better outcomes in terms of the levels of support needed for self-care and other daily activities as well as a reduction in the rate of substance use. They write:

Many participants reported issues with coercion and lack of agency as a result of court mandated participation in AOT. Participants under an AOT order mostly viewed their compliance with treatment as driven by fear rather than mutual agreement or shared decision making. One participant said “they just told me if I don’t take my medication and if I don’t—or if I relapse anything, then I will go back to the hospital.” Another participant reported fear of voicing any opposition during AOT hearings:

A third participant said that AOT felt much the same as being on probation:

Participants reported a lack of due process and not being given alternative options to involuntary treatment. Entry into AOT frequently occurred during times when the participants were powerless, such as having to agree to AOT to get discharged from psychiatric detention or avoid criminal charges. Court hearings overwhelmingly resulted in AOT approval (over 95%) and were rarely contested. Participants reported not understanding how or why their AOT orders were extended, which often made them feel that state oversight of their mental health treatment would continue indefinitely. The authors also note that enforcement practices disproportionately impacted people of color.

The authors make a number of recommendations for improving mental healthcare in the state of New York, including expanding voluntary pathways to services, improving transparency and understanding around AOT rights and processes, enhancing the quality of legal representation during AOT hearings, improving dignity in enforcement practices, increasing accountability and oversight, and reforming AOT enforcement and renewal practices.

This study had five key limitations. Some unmeasured clinical differences could not be fully controlled between the AOT and ACT groups. The interviews were only conducted with people under an AOT order that had the capacity to consent to participate in research. This means the voices of those with the most severe symptoms and those that were the most hostile towards this system were excluded. Inconsistencies in record keeping between different New York counties restricted uniform tracking of participants. Due to the AOT orders prioritizing participants for specialized care, the authors had difficulty in completely isolating the impact of the court order from the greater access to services. As this research was conducted within the state of New York, generalizability to other populations is limited. The authors conclude:

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New York State Office of Mental Health. (2026). Independent evaluation of New York State assisted outpatient treatment: Final report. (Link)