Nearly two decades ago, in a Manhattan subway station, a mentally ill man shoved Kendra Webdale, a promising young writer, to her death in front of an oncoming N train.
It was a horrific crime that shocked the city and the nation, highlighting deep flaws in the care of seriously mentally ill people and spurring a wave of state laws that use court orders to move them into outpatient treatment.
Last week, the man who killed Ms. Webdale, Andrew Goldstein, now 49, who has had schizophrenia since his youth, walked out of prison and into a mental health system that has been heavily influenced by his crime.
But whether those reforms have fundamentally improved that system — or just patched it over — remains an issue of intense debate among lawmakers, doctors and other mental health specialists. The so-called Kendra’s Law program in New York, for example, is considered to be successful when it is used. But advocates and critics alike say it is underutilized and underfunded.
“There’s still so much further to go,” said State Senator Catharine Young, an upstate New York Republican who has been one of the law’s chief supporters in recent years.
Now, 46 states have some version of the program popularized by Kendra’s Law, known in the mental health lexicon as “Assisted Outpatient Treatment,” or A.O.T.
The effectiveness of consistent treatment on the most seriously mentally ill, with or without a court order, is widely acknowledged. The treatment required by Kendra’s Law in New York is proven to reduce a patient’s risk of hospitalization, suicide and violence.
Championed by Ms. Webdale’s family, Kendra’s Law sought to plug cracks that Mr. Goldstein had fallen through. Records showed that he had been hospitalized more than a dozen times before killing Ms. Webdale, including one stay in the hospital just six weeks prior.
Kendra WebdaleCreditvia Associated Press
He was repeatedly released to live on his own, where he often shirked treatment, he later acknowledged.
Under longstanding law, people who are a danger to themselves or others can be committed to a psychiatric ward. But then there are those who are not deemed an immediate danger and thus do not meet that standard.
That was the case for Mr. Goldstein before he pushed Ms. Webdale to her death.
Under Kendra’s Law, individuals like Mr. Goldstein can be brought to court and ordered to undergo outpatient treatment, including taking medication. There is no criminal penalty if they don’t comply, but research has shown the program is effective.
Assisted Outpatient Treatment programs also require state health systems to prioritize patients with court orders, moving them to the front of waiting lists for treatment.
Advocates of this approach say it provides incentives for seriously mentally ill people to stay in treatment. Critics respond that the programs drag some of the most vulnerable patients through legal proceedings, only after the mental health system has failed them elsewhere. They also point to racial disparities in how the law is applied.
As of Tuesday, there were 3,158 patients under active Kendra’s Law court orders in New York, according to state statistics.
There are more patients who could qualify for the program based on their mental health and criminal histories. “We guess that there should be around 8,000,” said D. J. Jaffe, an advocate of Kendra’s Law who is the executive director of Mental Illness Policy Org.
Kendra’s Law restricts who can petition the courts to get patients into treatment. Doctors and parole officers can initiate the process, but the burden often falls on family members.
“One of the problems we have with the current Kendra’s Law is family members aren’t aware that it’s available as a resource,” Senator Young said. “The research clearly demonstrates that Kendra’s Law has been effective in helping the seriously mentally ill get the help they need and increasing public safety. However, it is greatly underutilized.”
Mr. Goldstein was sentenced to 23 years in prison, but was released after 19 years because of good behavior.
Despite years of treatment behind bars, Mr. Goldstein remains far from well. On the afternoon of his last day at Sing Sing prison, he frequently rambled during an interview.
He said that he hoped to be admitted to Creedmoor psychiatric hospital in Queens, where he spent time before his imprisonment. He said he knew he could not be trusted to maintain treatment on his own, and he would feel safer if someone was there to make sure he took his medication.
Mr. Goldstein said he knew that he killed Ms. Webdale, and while staring at his dirtied Converse sneakers, he described that day in 1999.
But he added: “I still don’t know how responsible I am for that death.”
It is unclear if Mr. Goldstein himself qualifies for care under Kendra’s Law, which requires that a patient has been hospitalized or jailed, or has committed an act of violence, within the previous 48 months — and that the patient has not been compliant with treatment.
Mr. Goldstein’s history before his imprisonment would have qualified him. However, Kendra’s law did not go into effect until November 1999. Asked what that discrepancy meant for Mr. Goldstein’s future, experts were split.
Mr. Goldstein was released on Thursday to “another state agency,” the Department of Corrections said. The court order was sealed and no more details were available.
Families of mentally ill people in Kendra’s Law programs said the threat of a court order was often enough to prompt a loved one into treatment.
“That was the magic trick,” said Susan Marasciulo, who said her mentally ill son had his life transformed by Kendra’s Law. “That was the turning point.” She and her husband referred him into the program after a series of hospital stays and an episode involving the police.
Her son left the program a decade ago, she said, and has complied with treatment since, including after the family moved to South Carolina.
Assisted Outpatient Treatment is twofold. It requires the mentally ill to get treatment, and obligates state health systems to provide it.
“There’s very, very wide variability in A.O.T. programs across the country,” said Dr. Marvin Swartz, a psychiatry professor at Duke University, where he has helped lead several studies on the effectiveness of these programs. “New York is unique because with the legislation, it added the infrastructure.”
New York State budgeted $24.7 million for Kendra’s Law last year, Senator Young said, adding that the program could use more financial support. She introduced legislation to strengthen the law that passed the Republican-controlled State Senate, but it hasn’t passed the Democratic-controlled State Assembly.
Critics of Assisted Outpatient Treatment said the programs did not address broader problems in the mental health system.
“A number of the people that wind up on these programs are all too often people who are being failed by the system,” said Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services.
“Once you open that option, it lets the system off the hook,” he said. “You don’t want to write the system off; you want to push the system to respond.”
After the interview at Sing Sing, Mr. Goldstein said he was about to meet with his lawyer.
He said he was working with a legal team as he transitioned out of prison and, he hoped, into a Kendra’s Law program.
“It is a silver lining,” Mr. Goldstein said, during a moment of clarity. “If that’s what you’d call it.”
Reached later that week, a representative for the law firm Mr. Goldstein mentioned was troubled: Its lawyers had not worked with him in years.
Ali Watkins is a reporter for the The New York Times. You can follow her on Twitter @AliWatkins.
