The Law and Practice of Assisted Outpatient Treatment, Involuntary Removal, and Involuntary Admission in New York State
- Adrienne Anderson
- 5 days ago
- 64 min read
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Key Takeaways
Together, court-mandated outpatient treatment and involuntary removal and hospitalization represent a safety net for individuals who fall through the cracks in the system of voluntary care, often cycling through hospitals, jails, and shelters.
New York’s recent codification of a “grave disability” standard clarifies that individuals at substantial risk of physical harm due to their inability to meet their “basic needs” on account of their mental illness may be appropriate for involuntary removal.
A number of statistically rare but high-profile incidents has fueled public safety concerns and contributed to growing support for more assertive involuntary intervention.
For the population that does not require an inpatient level of care but has not been able to effectively engage in voluntary outpatient care, the Assisted Outpatient Treatment (AOT) program facilitates court-ordered community-based care.
Approximately 3,670 New Yorkers are under active AOT court orders; 45% are in New York City.
The share of AOT participants who are hospitalized, incarcerated, or homeless during their time in AOT is at least 60% lower compared to their lifetime rates prior to AOT.
The AOT program is limited by: delays in referral investigations, court proceedings, and service initiation; difficulty maintaining engagement with participants and renewing court orders for the most vulnerable; capacity issues with mobile teams; and inconsistent or untimely identification of appropriate individuals in inpatient settings.
For individuals who cannot live safely in the community, pose a risk of serious harm to themselves or others, or are unable to meet basic needs on account of their mental illness, New York’s Mental Hygiene Law authorizes involuntary removal for psychiatric evaluation and involuntary admission for continued care on an inpatient basis.
Recent data from NYC suggest most involuntary removals originate from “private dwellings,” such as homes and shelters, rather than public spaces, such as subways.
Despite recent investments and policy changes, capacity shortages and fragmented systems continue to impact inpatient and outpatient civil commitment in New York.
Ultimately, involuntary treatment is not a substitute for a well-functioning, voluntary mental health system, but it remains necessary when that system falls short.
Thank you to the subject matter experts who offered insights and feedback during the development of this paper. Any remaining errors or omissions are my own.
Introduction
In recent years, policymakers in New York State have struggled with how best to respond to the challenge of individuals with unmanaged serious mental illness (SMI), often combined with a substance use disorder. These individuals often become homeless and cycle through emergency rooms, jails, and shelters. Although violent incidents involving this population are rare, a number of tragic and high-profile cases—such as random subway attacks—have come to define the impact of unmanaged serious mental illness as a distinct public safety and quality-of-life issue in the public’s mind.
The public, not unreasonably, finds it difficult to understand how the mental health and broader human services systems are unable to fix the “revolving door” – a term commonly used to represent the cycle described above. This issue has intensified scrutiny of the mental health system and renewed debate about how to address risks posed by individuals who are threatening or likely to harm others or themselves, without undermining their civil liberties.
Notwithstanding the intensity of political and public policy focus on this issue, many of the key elements that govern how the mental health system engages with such individuals —particularly through involuntary treatment on an outpatient or inpatient basis—remain poorly understood. The purpose of this paper is to review the following mechanisms:
Court-mandated outpatient mental health treatment
Involuntary removal for purposes of psychiatric assessment
Involuntary inpatient psychiatric hospitalization
This paper’s focus on involuntary interventions is not intended to in any way minimize the importance of crisis intervention services designed to stabilize individuals without involuntary treatment. These services, as well as the broader system of clinical and social services, and resources, including housing, help many individuals with SMI live stably in the community. All such aspects of the mental health system are vitally important, but even when that system is functioning effectively, there will always be individuals who are not adequately served by voluntary care. It is in these cases, when individuals “fall through the cracks,” that involuntary measures play a critical role. This paper examines how those measures currently operate and how they can be improved to better support individuals’ long-term stability and safety.
Similarly, this paper will not explore in depth the history of deinstitutionalization, which dramatically changed the way in which society responds to and interacts with individuals with serious mental illness, but some context is important. The legacy of deinstitutionalization and the country’s failure to build a sufficiently robust community mental health system following the passage of the Community Mental Health Act in 1963 certainly contributed to the current crisis. Contemporary scholarship highlights “reinstitutionalization,”[i] happening through the massive growth in the carceral system, and “transcarceration,” or the movement of people between various types of involuntary institutions, as byproducts of deinstitutionalization.[ii] Other observers point out the additional, important role that housing policy has played in contributing to the destabilization of individuals who were already vulnerable to street homelessness, and saw their housing options gradually disappear through developments such as the closure of single room occupancy housing in New York City in the 1980s.[iii]
The government’s duty to protect vulnerable people (i.e., “parens patriae”) and police power, or the government’s authority to protect the public, often intersect where mental health and the law overlap. The issue of civil commitment, both inpatient and outpatient, is a major subject in current policy debates about how to balance the rights of individuals and the expectations of society at large. It is, therefore, all the more important that there be a deeper and more nuanced understanding of these issues as policymakers and the public develop their perspectives.
While sentiments are strong about these issues, they are technical subjects that are not widely understood either in terms of legal requirements or operational aspects. This paper explains both the legal standards involved in these interventions and the operational issues in their implementation.
A note about serious mental illness and violence: Interventions such as involuntary commitment and court-mandated outpatient treatment are often criticized as not only violating the civil rights of those directly affected, but for stigmatizing the larger population of individuals with mental illness. It is important to correct a common, stigmatizing misperception that directly associates SMI with violence.
Serious mental illness encompasses a wide range of conditions and symptoms, some of which may incline a person toward antisocial or violent behaviors, and some of which may incline them against it.[iv],[v] Persistent paranoia and command hallucinations are two examples of “positive” symptoms of schizophrenia that may make an individual more prone to violence, often out of perceived self-defense from a threat that is only real within a delusion. The additional use of substances that alter one’s perception of reality or weaken impulse control and behavioral inhibition can also make an individual more prone to erratic acts, some of which may be harmful, if not intentionally violent. In contrast, research has suggested that “negative” symptoms of schizophrenia, such as apathy and social withdrawal, are associated with relatively lower rates of violence.[vi]
Research confirms that violence is statistically rare among people with serious mental illness. In a nationally representative study, 2.9% of individuals with SMI committed a violent act over a two- to four-year period. The rate was higher—10%—among those with both SMI and co-occurring SUD. Still, more than 97% of people with SMI alone, and 90% of those with SMI and SUD, were not violent during the study period.[vii]
Acknowledging this rarity, the highest-profile incidents highlighting the common association between mental illness and violence are those that occur in public places and mass transit. They are often shocking because the perpetrator and the victim typically do not know each other, so the act is effectively random, leaving passersby to wonder if they are “next.”
One such phenomenon has affected New Yorkers for decades: researchers in 1992 who analyzed information available about 20 of the 49 NYC subway pushings that occurred between 1975 and 1991 found that at least 19 perpetrators were psychotic at the time, with at least 13 experiencing active hallucinations, and all victims were strangers.[viii] A similar analysis of perpetrators has not been done in more recent years, but the number of such incidents has risen from the 49 over the 16 years of the aforementioned study: 29 people were pushed onto subway tracks in 2022, 17 in 2023, and 26 in 2024, or about one every two weeks.[ix]
Still, the family members of individuals with untreated SMI are much more often the victims of such violence[x]—a fact that may explain the New York City statistic from 2024 that the vast majority of involuntary removals came from private dwellings.[xi]
Importantly, SMI can be managed, and with the right resources, individuals affected by these conditions can live stably and independently. However, as is often the case with people who are marginalized, fearful and distrustful (often due to negative past experiences with punitive approaches), uninsured or underinsured, and unsheltered, their ability to consistently access the right combination of pharmacologic and non-pharmacologic treatments is especially difficult. As this paper will later describe, periods of disengagement from care, worsened by cyclical transitions between settings (e.g., hospital, jail, shelter), represent significant vulnerabilities along the care continuum and deserve close attention.
It is also important to note that modern research supports the efficacy of primary prevention interventions (i.e., designed to prevent incidence of disease) for psychosis, bipolar disorder, and some other common mental illnesses.[xii] Early identification and non-punitive, evidence-based interventions for children and young adults are essential to interrupting cycles of SMI and violence alike and are the most upstream solutions available to address these challenges in the long term.
Objectives of Involuntary Treatment
Involuntary treatment is a legal process by which a person can be ordered to mental health treatment without their permission or against their will, either in the form of court-mandated outpatient treatment or involuntary commitment to a psychiatric inpatient unit. Involuntary mechanisms exist primarily to ensure the provision of psychiatric care to people who refuse voluntary services for their mental illness and, in doing so, risk harm to themselves or others. Its goals are not punitive but rehabilitative and focused on safety and stability.
A secondary function of civil commitment is to protect others from potential harm by individuals who have threatened harm to others. Media coverage may make it seem that the detention of “dangerous” individuals to protect the public from random acts of violence is the primary purpose of involuntary commitment. In fact, the small subset of individuals with SMI who do commit acts of violence toward others are disproportionately likely to target family members.[xiii] Moreover, some clinicians in this field argue that substance use is at least as common a factor for violent actions as serious mental illness alone. Still, the small number of random attacks of violence that do occur have a disproportionate impact on the broader community’s sense of safety and quality of life.
The next section examines court-mandated outpatient treatment, an alternative to inpatient commitment for certain individuals who do not require the intensity of or have the clinical acuity necessary for hospital-based care, but still need structured, supervised services in the community. The final section discusses involuntary removal for psychiatric evaluation and involuntary psychiatric inpatient hospitalization, which apply to individuals who meet statutory criteria for immediate intervention and require the level of supervision and care that only inpatient settings can provide.
Court-Mandated Outpatient Treatment
Overview
The emergence of various community-based treatment services has fundamentally shifted the paradigm of mental health care delivery in the decades since deinstitutionalization. While the vast majority of such care is provided on a voluntary basis, the system has identified an involuntary outpatient model to reach the population of individuals who do not clinically require an inpatient level of care but are unable to effectively engage in traditional outpatient care. Such individuals include those stabilized in and “stepping down” from inpatient care, individuals in need of more clinical support following incarceration, and those who have a history of threatening harm against themselves or others.
Assisted Outpatient Treatment, or AOT, is the name of the model for mandating an individual to participate in community-based mental health treatment through a court order. Variations of involuntary outpatient treatment exist in 48 states nationally.[xiv]
New York’s AOT program is also referred to as Kendra’s Law, the name of its authorizing legislation, which was originally enacted in 1999. Kendra Webdale died in January 1999 after being pushed in front of a New York City subway train by a man with a history of mental illness and psychiatric hospitalizations. Kendra’s Law established new mechanisms for identifying individuals who, due to their treatment history and circumstances, will likely have difficulty living safely in the community without close supervision and mandatory treatment.
Following the law’s enactment, the New York State Office of Mental Health (NYS OMH) adopted regulations to support local mental health systems, giving AOT recipients priority access to care coordination and other services necessary to ensure their safety and successful community living.
Kendra’s Law required each New York county to establish a local AOT program and charged NYS OMH with monitoring and overseeing its implementation statewide. Implementation of Kendra’s Law and AOT has been a joint responsibility and collaboration between NYS OMH Central Office staff, NYS OMH Field Office staff,[1] and local mental health authorities, referred to here as LGUs, for local government units, and DCSs, short for the Director of Community Services title. MHL § 9.60 provides direction for the administration of AOT in New York State.
As with involuntary removals and inpatient civil commitment, outpatient civil commitment is subject to concerns about participants’ civil liberties. As the “Services” section will describe, though, the services available to AOT participants are the same services individuals would engage with on a voluntary basis; there is just a court mandate that the individual and their providers are, together, accountable to a time-limited treatment plan.
Participation in AOT is not a criminal process, and failure to comply with AOT is not a criminal offense, so non-compliance does not immediately result in consequences for participants. The “teeth” of noncompliance with AOT is the potential for involuntary removal for purposes of psychiatric evaluation, but only under strict conditions. Otherwise, an individual on AOT is subject to the same standards for involuntary admission as anyone else.
The available data on three key outcomes for AOT participants in New York State offer a compelling snapshot of the program’s benefits during the course of AOT:
As of May 29, 2025, there were 3,670 individuals under active AOT orders statewide, 1,638 (45%) of whom are in New York City. More data on the scale of and outcomes from the program are available later in this section and in the Appendix.
Ultimately, AOT is the law and has recently gained traction in public opinion and among elected officials, partly in response to some of the public safety concerns described in the Introduction. This section describes New York’s AOT program at length and offers recommendations for some known challenges.
Eligibility Criteria
AOT has a complicated array of eligibility criteria. Eligible individuals must: be at least 18 years old, have a mental illness, and be unable to live safely in the community without supervision. They must have a history of treatment noncompliance that has led to either: two or more hospitalizations in the past 3 years or serious violent behavior or threats in the last 4 years (excluding periods of hospitalization or incarceration), or a court order for AOT that expired within the last 6 months and after which their symptoms worsened and impacted major life activities. They must be unlikely to participate in outpatient treatment voluntarily, must need AOT to prevent relapse or serious harm, and, critically, because it has introduced subjectivity to an otherwise standardized process, must be “likely to benefit” from AOT.
The FY 26 Enacted State Budget slightly clarified the criteria as follows:
The MHL § 9.60(c)(4)(iii) criterion regarding the impact of worsened symptoms following an expired AOT order was clarified—from requiring interference with “major life activities,” to either a) substantial interference with the person’s ability to follow recommended treatment or b) consequences such as emergency observation, inpatient admission, or incarceration due to noncompliance.
Apparently, the original phrasing for eligibility of individuals with recently expired orders was widely seen as vague; the recent modification was intended to clarify the language to reflect its original intention rather than introduce a new threshold.
To the “likely to benefit” language, from MHL § 9.60 (c) 5, added “non-compliance with court oversight or mandated treatment shall not preclude a finding that the person is likely to benefit from assisted outpatient treatment.”
If an individual meets most AOT eligibility criteria but has not utilized intensive services in the past, then, in some counties outside of NYC, they may first be considered for a “voluntary agreement” or “enhanced service package,” typically of intensive care management services.[xv] This arrangement allows for monitoring of compliance, but there is no court order and the person is not subject to removal through the AOT program for non-compliance (though technically anyone is subject to involuntary removal laws), and it can be revoked at any time. The contract involved in a voluntary agreement facilitates the participant’s consent for the release of their personal information to their provider(s).
Process
Individuals are generally identified as candidates for AOT through one of two pathways: community referral, or identification of potential participants in the community, or institutional referral, in which potential participants are identified before their discharge from inpatient care or release from jail or prison. The frequency of either referral type varies widely by county. In NYC, the sources of referrals to AOT are, in order by volume: hospitals, the community, State-run hospitals, and New York State and NYC Corrections.
In the community referral process, concerned individuals (e.g., roommates, family members, providers, parole or probation officers) make referrals to the local AOT program. LGU AOT staff are expected to “timely” investigate whether the referred person meets criteria. If so, the local authority (i.e., LGU AOT staff) files a petition in the appropriate local court, which will hold a hearing within three business days of the petition to review each individual’s case and proposed treatment plan.
Previously, there was no clear benchmark in law, regulation, or guidance for what constituted timeliness; however, in 2024, NYS OMH established the standard at six months.[xvi] The time between identifying a candidate for AOT and getting an active treatment plan in place can vary and can be especially long in the community referral pathway: an individual can decline to share their medical records, at which point the county must subpoena the records, leading to considerable delays.
In the institutional referral process, hospital, jail, and prison staff must be sufficiently well-versed in AOT referral criteria to recognize appropriate patients or incarcerated individuals and evaluate the patient while still in their respective custody.
On the hospital side, hospital staff sometimes have difficulty retaining the person on an inpatient basis until the AOT order is in place, resulting in an unsupported, vulnerable transition. If a person in the hospital meets AOT criteria, it may take two to three weeks at the earliest (usually four or more) before they can proceed with AOT. It is therefore important that hospital staff start thinking about potential AOT eligibility at the time of admission, not just upon discharge. NYS OMH has its own screening tool for assessing individuals in its Psychiatric Centers within 30 days of admission and reviewing the screening again prior to discharge.
If a hospital determines, based on screening and record review, that an individual in its care is an appropriate candidate for AOT, the hospital will connect with local AOT staff, who will review the hospital’s justification, its proposed treatment plan for the individual, and will verify that all of the providers listed in the plan are legitimate and agreeable to participation. The local AOT staff will designate a physician from the hospital to examine the patient and testify in court. Essentially, the hospital will assemble the case and propose a plan, the county will approve the plan, and the judge will make the ultimate decision.
On the carceral side, if a person who is receiving mental health treatment is approaching release, they can be referred to AOT, in which case the court order is local to the county of the jail or prison, and, once granted, the treatment plan is later transferred to the county to which the person is released.
The process of developing the treatment plan for an AOT order varies depending on the pathway of referral. In cases of community referral, where, for example, a concerned family member is referring someone with little documented treatment history, the county AOT staff will help build a treatment plan in collaboration with treatment providers, social workers, and care managers, as well as the individual and any other parties they wish to include. In cases of community referral for an individual who has been recently engaged in care, where, for example, an Assertive Community Treatment (ACT) team is concerned about non-compliance by an existing ACT recipient, the county AOT staff will help the ACT team craft an appropriate treatment plan with the individual that accounts for their ongoing care.
States vary in the timing and degree of judicial involvement in the AOT order process. In New York, the judiciary is only involved when the order is granted and if and when it is renewed.[xvii] Judges have discretion to modify treatment plans, in extreme cases making what are effectively clinical decisions by removing a medication, for example, but more commonly by making changes more in the interest of the individual’s liberties, such as shortening the duration of the treatment plan. A later section will discuss how different levels of judicial involvement are believed to influence outcomes and administrative efficiency.
Once the court-ordered treatment plan is in place, it serves as a contract for all parties, not just the participant. Indeed, the judge, the providers of medical and human services associated with the treatment plan, and the participant are all technically beholden to the plan. This is considered an important aspect of the overall accountability of the model.[xviii]
Figure 1 from the February 2024 Kendra’s Law Audit Report by the Office of the New York State Comptroller concisely summarizes the process from referral to potential renewal:
Services
Once an AOT treatment plan is in place, individuals on AOT are ideally accompanied home after discharge from a hospital or court by their assigned care manager (from one of the three services described below) and receive an in-person visit to connect them with treatment services starting within one week of the court order.[xix],[xx]
The following is a useful slide from the New York City Department of Health and Mental Hygiene, describing these different services along a vertical continuum of intensity. Although the image was not designed in the context of AOT, its content matches the three types of services individuals on AOT receive, with Assertive Community Treatment (ACT) and, in New York City, Intensive Mobile Treatment (IMT), as higher-intensity offerings, and the pairing of outpatient treatment with care coordination as the lower-intensity offering:
The following table includes additional operational details about the three services from a statewide perspective:
| Assertive Community Treatment (ACT) | Intensive Mobile Treatment (IMT) | Care Coordination and Outpatient Treatment[2] |
Geography | Available statewide, but services are catchment specific and do not follow a person. Shelter Partnered ACT, for individuals residing in homeless shelters, is only available in NYC. Forensic ACT, for justice-involved individuals, is also more limited. | NYC only; services follow a person across boroughs.[xxi] | Available statewide through care management agencies authorized by NYS OMH to provide services to AOT participants,[xxii] and through outpatient clinic providers. |
Billable | Yes | No. 100% NYC tax levy funded. | Yes |
Frequency of Engagement | 6 times per month | Generally, at least 4 times per month. | Typically at least four care coordination visits per month with outpatient services as determined by individual needs. |
Share of NYC AOT[xxiii] | As of 2024, 46% of NYC AOT participants were engaged with traditional ACT, 4% with forensic ACT, and 4% with shelter-partnered ACT. Individuals on AOT orders represent 25% of ACT volume in New York State and 21% in NYC.[xxiv] | As of 2024, 7% of NYC AOT participants were engaged with IMT. | As of 2024, 38% of NYC AOT participants were engaged with care coordination and clinic treatment. |
In New York City, to determine whether an individual’s treatment plan will include ACT or IMT, AOT staff from the New York City Department of Health and Mental Hygiene (DOHMH, here as the LGU for New York City) coordinates with the single point of access (SPOA), which handles all referrals to ACT (and its variations) and IMT. For example, if a hospital proposes a treatment plan for its patient that includes IMT but there are no open slots, and the SPOA finds they meet ACT criteria, DOHMH staff and SPOA staff will modify the proposed treatment plan, ideally before the psychiatric examination, but at least before the hearing.
Treatment plans may include “contingencies,” which allow for adjustment based on participants’ response to the initial treatment plan, for example, substituting one medication for another to avoid the side effects of the original.[xxv] Contingencies do not require any parties to return to court, since they were already included in the approved treatment plan.
Contingencies can also be useful for creating a “Plan B” if the primary service type is not available (i.e., there is a waitlist) by the time the order is approved. For example, an individual in New York City may meet ACT criteria, requiring a fairly high-intensity service, but when their order is approved, there are no available slots. A treatment plan with a contingency for IMT would allow the individual to access that service in lieu of ACT, provided an IMT slot was available. Contingencies also allow flexibility to adjust the treatment plan if another service becomes available, for example, by initiating someone on lower-intensity care coordination and outpatient clinic services until a slot becomes available in either higher-intensity service.
Technically, MHL § 9.60 only requires care coordination, with medication being one optional component of the court-mandated treatment plan. Still, NYC data from 2024 indicate that 99% of active AOT participants had medication on their treatment plans, with 86% of participants specifically receiving long-acting injectable antipsychotic medications.[xxvi]
One common misconception about AOT is that participants are medicated against their will. This is not the case, as “medication over objection” is not legally permitted in community settings. Another misconception is that medication adherence effectively guarantees success. Some 30% of individuals with schizophrenia have “treatment-resistant” schizophrenia, which is non-responsive to multiple initial attempts at treatment with antipsychotic medications,[xxvii] and treatment resistance across psychiatric disorders ranges between 20% and 60%.[xxviii] There are both emerging and existing, underused treatment modalities that can be effective for those with medication treatment-resistant conditions, but it takes a dedicated, knowledgeable provider with adequate capacity to move a patient through alternatives, some of which may still fail.
Monitoring
Providers and LGU AOT staff play important roles in monitoring compliance with court-ordered treatment plans and identifying critical deviations from them. LGUs are required to report on their AOT participants[xxix] to NYS OMH Field Offices, which review a sample of AOT cases on a quarterly basis.
“Significant events” is the term of art for episodes that threaten the AOT participant or the community and negatively affect the participant’s stability and treatment plan.[xxx] These include but are not limited to, psychiatric hospitalizations, homelessness, arrests, incarceration, dangerous substance use, and “going missing” from treatment.[xxxi]
Once a care manager is aware of a “significant event,” they are obligated to report it to the appropriate county’s (or NYC’s) AOT program within 24 hours.[xxxii] Depending on the seriousness of the event (e.g., accusation of or arrest for serious crimes, interpersonal violence, threats or acts of harm against others or self, suicide attempts, missing from treatment with no contact for at least 24 hours since provider’s awareness), the county or NYC AOT program may be obligated to additionally report the event to its respective NYS OMH Field Office.[xxxiii] Such events may be catalysts for emergency evaluation or hospitalization, or changes to the treatment plan. In New York City, there is some bi-directional communication of significant events, with the NYC OMH Field Office alerting NYC (i.e., local) AOT staff about any incidents involving AOT recipients that are identified through the New York State Incident Management and Reporting System (NIMRS).
New York City, given its high share of AOT cases, has a more formal structure around its program operations and monitoring efforts. There are approximately 100 dedicated staff, including psychiatrists, lawyers, and monitors, many of whom are social workers. Caseloads are high, since the volume of AOT cases city-wide can exceed 2,000 in a given month. NYC AOT staff review weekly progress notes and hold monthly service verification calls to check for compliance, effectively providing a safety net for AOT, which is itself a safety net.
Non-compliance
Non-compliance with a court-ordered treatment plan is very common, considering past non-compliance is part of the eligibility criteria for AOT. If a participant fails to comply, their treatment team first works with them to achieve compliance. For example, an individual may find the side effects of a particular medication unbearable and may decide to stop taking it to avoid those effects. Ideally, a provider will discuss their patient’s concerns and modify the treatment plan as necessary to mitigate these ill effects.
If, after attempting to resolve the non-compliance, a provider determines that the participant still has not complied with the treatment plan, reasonable efforts to engage the individual have been unsuccessful, and the individual has decompensated to the point of potentially meeting criteria for involuntary hospitalization under MHL §§ 9.27, 9.39, or 9.40, a treating physician may request removal in accordance with MHL § 9.60(n). The individual can be transported to an emergency room (in NYC, this is done by the NYC Sheriff, not NYPD) for evaluation to determine their need for inpatient care and treatment.[xxxiv] The individual can be retained for up to 72 hours. Any decision to keep the participant beyond the initial 72 hours must be in accordance with the procedures for involuntary admission, outlined in the final section on involuntary inpatient hospitalization.
The physician may consider refusal to take required medication, or failure of a test to determine medication compliance or alcohol and/or illicit drug use in reaching a clinical determination on the appropriateness of removal to a hospital, although these alone are not legally adequate grounds for admission, and in practice, these are not typically sufficient grounds for removal.[xxxv]
Another, more challenging form of non-compliance is when AOT staff cannot locate a participant who has disengaged. Providers are required to conduct weekly “diligent searches” for these individuals both before and after the removal order is issued, until they are found or their AOT order expires.
Considering that a statewide average of 29% of AOT participants have been homeless prior to AOT, many of the challenges with serving a transient population are relevant here.[xxxvi] Among the unhoused population, street homeless individuals are especially challenging to engage in AOT: it is difficult to establish which county court has jurisdiction over their cases and to mail paperwork to places where they will realistically receive it.
Of note, simple non-compliance without decompensation (i.e., worsening of relevant symptoms) is not a sufficient basis for removal, and removal is not a sufficient basis for admission; admission is determined by a psychiatrist at the emergency department receiving the AOT participant.
Renewals and non-renewals
Per MHL § 9.60(k), counties must notify their respective NYS OMH Field Offices about whether they will pursue a continuation of AOT, or “renewal,” for each participant, as orders expire after one year. Renewal must be pursued within 30 days prior to an existing order’s expiration.[xxxvii] If a participant is not referred for renewal, the county must provide NYS OMH with the reason using the “Director of Community Services (DCS) Review and Determination of AOT Non-Renewal” form.
As a participant’s order nears expiry, a physician examines the participant and reviews the participant’s compliance during the order, the treatment course pursued through the order, and significant events that may have transpired during the order, if any.[xxxviii]
This process culminates in one of three outcomes:
If the participant has demonstrated likelihood of adhering to treatment on their own accord, the order may not be renewed.
If the participant still requires mandatory outpatient treatment, a new court hearing must occur to renew their order. The treatment plan of the renewal order may vary from the original.
If the participant no longer meets criteria for AOT but wishes to maintain the structure and supervision available through AOT, they may enter into a voluntary agreement for an enhanced service package for a period of six months or one year. It will be important to monitor whether the volume of voluntary agreements changes following the FY26 Enacted Budget clarification about individuals with recently expired orders, since some may be more appropriate for a step-down, voluntary arrangement than for AOT.
The underutilization of renewals is often cited by critics as a reason for the underperformance of the AOT program relative to its potential.[xxxix] Since the first available program data from November 1999, 56% of orders are renewed on average, statewide, and 54% in NYC. In the past 12 months (6/1/2024-5/31/2025), 53% of orders were renewed on average, statewide, and 47% in NYC.[xl]
The reasons for non-renewal, as of June 1, 2025, are depicted below:
Operational Challenges that Complicate the Renewal Process
Inability to serve notice
The SAFE Act of 2013 amended MHL § 9.60(k)(1) to authorize Directors of Community Services (DCSs) to petition for renewal of an AOT order even when an individual is missing and unable to be evaluated prior to the order’s expiration, and amended MHL § 9.60(k)(2) such that treatment orders remain in effect during the period between applying for renewals and awaiting a hearing.[xli],[xlii] Anecdotally, though, some county attorneys have taken the position that if the county cannot serve an individual the legally required notice of the petition to renew their AOT order, the county cannot technically renew the order.
In an effort to standardize expectations around these circumstances, NYS OMH amended the form that counties use to report renewals and non-renewals. Now, when a DCS completes the form and indicates that an individual is not having their order renewed but may still meet criteria for renewal,[3] the online form produces seven radio buttons to provide further detail. One reads: “The petitioner has actively attempted to locate and serve the recipient with the renewal petition, but the recipient's whereabouts remain unknown.” This communicates the State’s expectation that a county has done its due diligence in locating an individual who would otherwise be eligible for order renewal.
Missed opportunities during hospitalization
Experts believe that more AOT orders would be renewed if hospitals could more consistently identify when an individual in their care has an active AOT order within 30 days of expiration and could act quickly to initiate the renewal process. Emergency departments, Comprehensive Psychiatric Emergency Programs (CPEPs), and inpatient units can utilize PSYCKES to identify in real time when patients have active or expired orders.
In an ideal model, an automated process could alert county AOT staff and care managers when an AOT participant is removed or admitted to a hospital. In the case of renewals, with New York City as an example, NYC AOT staff would be alerted in real time that one of their participants had been admitted to Bellevue Hospital. AOT staff could arrange for a DOHMH psychiatrist to remotely examine the patient and pursue renewal in court.
“Likely to benefit” language
Until August 7, 2025, the “likely to benefit” criterion can be used to justify non-renewal if relevant parties determine a person has failed to benefit from the services provided during their initial court order. As mentioned earlier, though, the FY 26 Enacted State Budget modified the “likely to benefit” clause by appending it with: “Previous non-compliance with court oversight or mandated treatment shall not preclude a finding that the person is likely to benefit from assisted outpatient treatment.” This modification should ameliorate some of the impact of the subjective “likely to benefit” clause on non-renewal decisions.
Renewals aside, some proponents of the AOT program maintain concern over the “likely to benefit” clause as it creates a loophole that enables providers to avoid responsibility for particularly challenging individuals and denies some individuals the opportunity afforded by AOT’s priority access to services. Since AOT is essentially a safety net for individuals who have demonstrated past difficulty engaging with voluntary models of care, providers may have already had negative experiences with those same individuals on a voluntary treatment basis. Additionally, providers may be so overwhelmed by their existing caseloads that the prospect of accepting individuals they anticipate will create difficulties is particularly inconvenient, if not concerning.
Scale of AOT in New York State
AOT costs New York State approximately $29 million per year to administer,[xliii] though there are additional costs for which LGUs are responsible. NYS OMH collects a range of detailed metrics about the program, which it includes on a public reporting dashboard as often as daily, for some measures. Findings in this section are derived from that public dashboard as of June 1, 2025, unless otherwise stated.
In the 15 years between November 1999 and November 2024, statewide, there were 48,197 investigations conducted, 37,385 petitions filed, and 35,747 petitions granted (96%, both statewide and in NYC). New York City has accounted for about 47% of investigations and 61% of petitions filed and granted.
Compared to petition-granting rates of 96% from the entire duration of Kendra’s Law, past-year data (i.e., 6/1/2024-5/31/2025) show 87% granted statewide, and 84% in NYC.
As of May 29, 2025, there were 3,670 individuals under an AOT order, with geographic distribution by NYS OMH regions below.[xliv]
The average age of an AOT participant is 39. The sex split of 68% male, 32% female holds statewide and in NYC. Diagnostically, 70% of AOT participants statewide and 72% in NYC have a schizophrenia diagnosis; 14% statewide and 13% in NYC have a diagnosis of bipolar disorder. 51% of participants statewide and 52% in NYC have a co-occurring substance use disorder.
The dashboard includes a wider range of race and ethnicity categories, but for the sake of legible visualizations, any for which N=0 were omitted from these pie charts:
An October 2024 webinar[xlv] hosted by the Treatment Advocacy Center about AOT in New York City shared the following NYC-specific data from NYS OMH and NYC DOHMH:
In FY 24, 1,950 individuals were enrolled in AOT in NYC (54% of statewide census).
10% were sheltered homeless and 2% were unsheltered.
There were 2,658 active AOT cases and 829 removals; 60% of those removals resulted in hospitalization, while 40% received treatment but were not admitted.[xlvi]
AOT has grown on average, statewide and in NYC. An article published in 2022, closer to the impact of the COVID-19 pandemic, noted:
“As of September [20]22, the number of individuals under AOT in New York City had risen to 1,655, close to half of the state total, and a remarkable 19% increase over the same day last year. Long Island was the only other region in the state to see an increase, dwarfed by both the pace and volume in the city.”[xlvii]
Below, comparing point-in-time enrollment on May 30 of multiple recent years yielded considerable regional, even borough-specific variation, with Queens (+66% in four years) and Long Island (+34% in four years) standing out as growth areas:
Outcomes
Conceptual challenges with evaluation
Evaluating the efficacy of involuntary outpatient treatment is technically challenging for a few reasons. By defining people eligible for involuntary outpatient treatment in part by their likelihood to harm, they are inherently a more vulnerable population than those engaged in other types of treatment.
Comparison between people in AOT and people in voluntary outpatient treatment, even with the same diagnoses, is imperfect. A 2001 study of an early 1990s pilot precursor to AOT in New York City randomized individuals to involuntary treatment,[xlviii] but realistically, new research randomizing individuals to AOT, given the implications it can carry, is not feasible.
Further, because AOT involves a mandate that ultimately represents numerous potential clinical and social interventions, it is very difficult to determine causal relationships within its observed outcomes.[xlix] The attribution of, for example, improved medication adherence, could be to the involuntary nature of the AOT model, or it could be the result of a particularly effective prescriber, an especially engaging ACT team, or the circumstance of being stably housed after a period of homelessness.
Much of the formal research evaluating the efficacy and implementation challenges of AOT is, by modern research standards, outdated. Yet a formal evaluation of New York’s AOT program from 2009,[l] and its related publications are still widely cited in the literature, indicating a sustained research interest in the topic and a dearth of newer data of the same caliber. Indeed, the Biden Administration’s February 2023 “Report of Mental Health Research Priorities” included research on AOT in the category of research opportunities for fostering long-term engagement in care and recovery.[li]
Current outcomes
In 2023, NYS OMH procured an evaluation of the AOT program[lii] that is now underway and should provide a valuable update on the efficacy of the program. In the interim, the NYS OMH public AOT reporting dashboard described in the previous section provides data on a range of valuable outcome metrics on the “Recipient Outcomes” page.
One particular area of interest is “significant events,” as described earlier in the “Monitoring” section, which can compromise stability in recovery and put the participant or others at risk. NYS OMH tracks these events throughout engagement with AOT through the reporting described earlier, and compares them to their incidence prior to individuals’ AOT enrollment:
The “Recipient Outcomes” dashboard also includes measures on engagement and adherence, service participation, and harmful behaviors, among other categories. Broadly, the available data on AOT indicate consistent reductions in all measures of harmful behavior, improvements in medication adherence and service engagement measures, and considerable, even exponential, increases in measures of service participation.
Additional AOT measures are presented in an aggregated, statewide and NYC format in the Appendix.
Specific areas for future research
While a range of operational and outcomes data are available through NYS OMH, a few areas warrant additional research attention.
How do outcomes vary for participants with co-occurring substance use disorders, compared to those without? For participants who are unhoused versus housed?
Racial disparities in enrollment in AOT have been well-documented. How do outcomes vary by race and ethnicity?
Some research has indicated inconsistency in who is referred to AOT.[liii] How much do factors such as family advocacy, clinician awareness, or need for priority services determine whether an individual is referred to AOT?
The 2001 randomized study mentioned earlier indicated that housing and substance use disorder each played a role in participants’ outcomes in AOT. Which elements of AOT most mediate outcomes of engagement and retention in treatment?
What are the cost savings associated with reduced incarceration and hospitalization rates due to AOT, relative to its expense?[liv]
Challenges and Recommendations
The FY 26 Enacted State Budget provides $16.5 million to enhance county-level implementation of AOT programs and $2 million for NYS OMH to add staff dedicated to monitoring AOT, enhance statewide training, and provide additional support for counties and providers.[lv]
Still, there are several challenges that limit the efficacy and reach of AOT:
1. Delays in timely court proceedings and initial treatment
A significant barrier to AOT’s effectiveness is any delay in the investigation of a referral or the initiation of services after a court order is issued. Among the deficiencies identified in the New York State Comptroller’s February 2024 audit[lvi] of New York’s AOT program were LGUs’ untimely investigations of AOT referrals and delays before treatment started, once an order was in place.
In NYS OMH’s 180-day response letter,[lvii] the agency shared that it had established a six-month timeframe for investigations of referrals (as mentioned in the “Process” section), educated the LGUs on that standard, and implemented new electronic processes for reporting on timely investigations and on monitoring of AOT orders set to expire. Also in that letter, NYS OMH shared its plans to begin tracking timeliness of initial treatment, but conceded that real-time data collection was not currently feasible.[lviii]
In that audit process, NYS OMH alluded to the New York Court of Appeals ruling in the 2011 In re Miguel M. case as one source of delays. In that case, the Court ruled that the release of a patient’s mental health records for the purpose of determining the need for AOT without that person’s notice or consent is inconsistent with the Privacy Rule of the federal Health Insurance Portability and Accountability Act (HIPAA).[lix],[lx] The impact of this ruling has been significant, since, if individuals do not consent to sharing their medical records, their records must be obtained through subpoenas, which are time-consuming and administratively burdensome.[4] This most impacts referrals from the community and from jails and prisons.[lxi]
Looming over the AOT program is the challenge of an overburdened civil court system, especially in Manhattan and the Bronx. Backlogs in proceedings can result in considerable delays for hearing new petitions.
Recommendations: In addition to the efforts NYS OMH has already begun, a combination of the following would improve the efficiency of AOT administrative processes: Add dedicated staff resources to overburdened local AOT staff, such as in NYC, since the program continues to serve more individuals each year. Given the difficulty of acquiring records for community referrals, ensure hospitals’ staff are well-trained on screening (and do so early in an admission) and petitioning for AOT. Address docket bottlenecks and fill vacancies in civil courts to create more capacity for timely hearings
2. Discharge and release transitions
Discharge and transition planning for AOT participants often fails to ensure continuity of care between inpatient and outpatient settings. A recurring issue is the lack of coordinated, accompanied or “warm” hand-offs at the point of hospital discharge. Despite the willingness of some housing providers or care teams to meet clients at the hospital, hospitals do not consistently initiate communication or allow external providers to participate in the discharge process. This results in missed opportunities to stabilize individuals during a critical transition.
NYS OMH and New York State Department of Health (DOH) program regulations approved in December 2024 now require hospital staff to:
“Check PSYCKES for prior psychiatric and medical history, wellness plans, and psychiatric advance directives when admitting patients;
obtain information from outpatient providers and other collateral sources of information to help inform hospital assessment, treatment, and discharge planning;
determine if the individual has complex needs based on a new clear definition; conduct screenings for suicide risk, substance use, violence risk – including asking about access to firearms or other weapons;
establish a discharge plan reflecting the individual’s social support levels and address psychiatric, substance use disorder, chronic medical, and social needs;
connect with outpatient or residential programs for patients having complex needs on the day of discharge or as soon as possible afterward; schedule follow-up appointments within seven calendar days or the earliest possible date after an individual is discharged;
coordinate discharge details with care managers for those enrolled in outpatient or residential care management;
screen for suicide risk prior to discharge; and
offer appropriate pharmacological interventions for substance use disorders and consider long-acting injectable medications for individuals with a history of difficulty consistently taking oral antipsychotic medications.”[lxii]
Although the PSYCKES system contains key information—such as AOT status and, sometimes, AOT care manager contact details—its utility is undermined by inconsistent data availability and underuse by hospital emergency and inpatient staff.
Joint guidance issued by NYS OMH and DOH in October 2023 included an AOT-specific expectation for Article 28 and Private Article 31 Psychiatric Inpatient Units:
“Individuals who have an elevated risk or frequent admissions due to non-compliance should be evaluated to determine if AOT would be beneficial.”[lxiii]
Recommendations: In addition to the uses described in the regulations above, hospital staff should also consult PSYCKES to ascertain whether an individual has an active or expired AOT order, and should contact the care manager whenever an individual on AOT is admitted or discharged. This would help AOT staff intervene proactively in the event of a vulnerable discharge and communicate with community providers as necessary, in the event of an admission. Further, since providers that are operated or licensed by NYS OMH are expected to report significant events to the New York State Incident Management and Reporting System (NIMRS) in a timely manner, it would be worth exploring whether reports of incidents involving AOT participants could be automatically generated and communicated to counties. While incident reporting into NIMRS does not capture the full universe of services and settings relevant to AOT participants, and NIMRS incidents[lxiv] do not completely overlap with significant events in the AOT context, there is significant overlap. Streamlining even some portion of significant event reporting could reduce provider administrative burden from duplicative reporting and provide more immediate, actionable alerts to county AOT staff.
3. Capacity issues with team-based services and housing
Over 1,000 people are currently on ACT waitlists,[lxv] and nearly 700 are waiting for IMT services.[lxvi] Although AOT participants have priority access, their access is not necessarily immediate, as explained in the earlier description of contingencies. In addition to the often extensive time between identifying an AOT candidate, making a referral, and having a treatment plan in place, individuals may have to wait for slots to become available in higher-intensity care management services.
Housing is a core social determinant of health; safe, stable housing can be the difference between success and “significant events” for an AOT participant. NYS OMH recognizes the importance of the appropriateness of an individual’s residence in its formal guidance to AOT programs, noting that if a DCS determines that an AOT participant’s residence will compromise their ability to live safely in the community, they should document the reason and any recommended alternative placement, and attempt to arrange for that alternative placement, also documenting the availability of alternatives, and the willingness of housing providers to accept the participant, and of the participant to accept the placement.[lxvii]
Stable housing would likely improve participants’ compliance, outcomes, and long-term stability. Yet currently, individuals on AOT do not have priority access to housing, the way they do treatment services, and have no designated vouchers or other resources for housing placement,[lxviii] despite their considerable vulnerability. In New York City, the Human Resources Administration (HRA) assesses shelter residents for housing placements without input from NYC AOT staff, who have relevant insight about the individuals in their purview.
Recommendations: Involve local AOT staff in the housing placement process and prioritize some portion of supportive housing for unhoused individuals on active AOT orders.
4. Substance use disorder treatment
Roughly half of AOT participants have a co-occurring substance use disorder (SUD). According to NYS OMH data, available in the Appendix, approximately 11% of AOT participants are engaged in SUD services prior to AOT, and 36% are engaged after the entire duration of the order. While this growth is impressive, the final treatment engagement rate is still much lower than the rate of SUD among AOT participants.
Anecdotally, even when SUD treatment is included in treatment plans, it is not as rigorously enforced. This is partly because the enforcement mechanisms in AOT are not appropriate or effective responses to non-compliance with substance use treatment. While AOT can support engagement in services for co-occurring SUD among individuals with serious mental illness, the nature of addiction care requires different strategies and supports.
Although data about rates of individual substance use disorders among AOT participants are not publicly available, stimulant use disorder, which is associated with erratic, impulsive, and potentially violent behavior,[lxix] is rising and will pose considerable challenges, as there is currently no pharmacological intervention for it. In contrast, there are highly effective, evidence-based treatments for opioid, alcohol, and tobacco use disorders, which are available in a range of community-based settings.
Recommendation: As clinically appropriate, include evidence-based, accessible SUD treatment in AOT participants’ treatment plans, particularly medication for addiction treatment (MAT) for those with tobacco, alcohol, and opioid use disorders.
5. Use of virtual psychiatric testimony
Currently, individuals referred to AOT must consent to a virtual psychiatric examination for an initial or renewal order. Although judges have the authority to waive in-person testimony, some are hesitant to do so. Requiring psychiatrists to appear in person for testimony places a financial burden on the counties that are paying for the psychiatrists’ time. If psychiatrists must wait for their turn to testify in each hearing, that represents time that could be spent seeing patients.
Changes proposed in the FY 26 Executive Budget proposal would have amended MHL § 9.60(h)(2) to remove the following language, but the modification was not adopted in the Enacted Budget:
“Provided however, a physician shall only be authorized to testify by video conference when it has been: (i) shown that diligent efforts have been made to attend such hearing in person and the subject of the petition consents to the physician testifying by video conference; or (ii) the court orders the physician to testify by video conference upon a finding of good cause.”[lxx]
Recommendation: Allow virtual psychiatric testimony by default for initial and renewal orders to lower counties’ costs, improve the efficiency of court proceedings, and save psychiatric examiners’ time.
6. Variable approaches of county attorneys
County attorneys can have considerable influence over local implementation of the AOT program. As in the case of judges, county attorneys have variable familiarity with the goals and rules of AOT. Depending on the dynamic between a county attorney and the county’s DCS, AOT staff may be more or less deferential to the county attorney’s interpretations of relevant statute. Administration of the program can become especially complicated if the DCS and county attorney are not aligned with each other or if either is out of sync with State guidance and best practices observed in other counties.
There may be legitimate reasons for a county to diverge from standard practices, but subjective decisions about, for example, how much effort is adequate to try to locate a missing participant, have real impacts on individuals (especially in under-resourced communities) and are worthy of discussion and resolution.
Recommendations: Create regular opportunities for county attorneys to convene to discuss difficult cases and access trainings tailored to their role. Address relevant guidance and other communications to audiences beyond DCSs and providers; include county attorneys and judges.
7. Allocating judges to AOT
The involvement of a judge or magistrate varies in AOT programs across the country. New York’s model is considered to have low judicial involvement, as judges are only involved at the beginning and end of the program. In contrast, models with high judicial involvement have regular appearances before the judge (or magistrate).
An analysis of data from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) AOT Grant Program for Individuals with Serious Mental Illness[lxxi] found that models of high judicial involvement generally more collaboratively and clearly define the judge’s role and communicate expectations for that role to the involved parties. Judges in these higher-touch models spend more time educating participants about AOT and the rationale for their petitions and may use hearing time to thoroughly review a participant’s treatment plan. They may allow participants to speak during their hearings, and consistently demonstrate courtesy and respect for the dignity of individuals before them. They may hold hearings quarterly, monthly, or ad hoc, in contrast to New York’s model, which is effectively annual. In the SAMHSA analysis, AOT program staff reported that judges’ personal engagement and relatively frequent contacts helped build trust with participants and increased their motivation and treatment adherence.
Although research has not yet determined the exact mechanism of how higher judicial involvement directly impacts programmatic outcomes, this so-called “black robe effect”[lxxii] is understood to positively impact AOT programs’ efficacy.[lxxiii]
Operationally, dedicating judges to AOT cases can facilitate efficiency by consolidating examinations and reducing unnecessary use of physicians’ time.[lxxiv] Judges who are repeatedly assigned AOT cases develop more familiarity with the complexities of MHL § 9.60 and may be more flexible, for example, showing more openness to virtual testimony, which can lower costs, as described above.
Recommendation: In its first annual report issued in February 2025, the New York State Unified Court System’s Judicial Task Force on Mental Illness recommended that the New York State Offices of Court Administration and of Mental Health establish a two-year pilot of a model with higher-judicial involvement.[lxxv] Such a pilot, combined with an effort to dedicate certain judges to hearing AOT cases (ideally consolidating cases into certain days and scheduling psychiatric testimony in blocks), may improve participants’ engagement with AOT and produce long-term efficiencies from the court’s perspective.
Involuntary Removal and Involuntary Hospitalization
Overview
While Assisted Outpatient Treatment is designed to support individuals “stepping down” from hospital care or aiming to avoid it, some individuals require a higher level of care. In such cases, involuntary removal to a hospital for psychiatric evaluation, and, depending on the circumstances, involuntary inpatient admission may be warranted.
Transporting individuals against their will to a hospital for psychiatric evaluation is referred to as “involuntary removal.” The criteria for involuntary removal overlap closely with the standard for involuntary hospitalization. The professionals involved in effectuating an involuntary removal do so based on their expectation that the involuntary admission standards would be met when the individual is assessed by clinicians at the hospital.
It should be noted that the care provided in modern State-operated psychiatric centers and psychiatric units of general hospitals is evidence-based and dramatically different from the treatment offered in institutions prior to deinstitutionalization. For example, there have been concerted efforts to reduce overmedication (especially unnecessary polypharmacy, which is the administration of a combination of prescription medications, often resulting in a sedated, lethargic effect on the individual), as well as the use of restraints and the practice of seclusion.
Many individuals with serious mental illness credit involuntary inpatient care with providing them with life-saving stability and safety. On the other hand, some point out retraumatizing behavior and challenges with treatment itself, such as significant side effects from medications, antipsychotics in particular.[5] The concerns of the latter group should be taken seriously and remedied. Inpatient treatment today can be productive for individuals with serious mental illness, but it is important to ensure individuals are always treated with dignity and are safe in the care of these facilities.
There are some instances in which there is enough evidence of potential harm that we may be justified in protecting the physical safety of any number of people at the temporary expense of one individual’s liberty. For example, Martial Simon, the man who shoved Michelle Go to her death on the New York City subway tracks in 2022, reportedly told a psychiatrist five years earlier that it was “just a matter of time before he pushed a woman to the train tracks.”[lxxvi] This threat, while vague about the intended target, was not rambling, but a prescient warning.
In other instances, it is more difficult to parse whether passive behaviors represent plausible threats to oneself or others. As described below, New York State recently codified what is known as a “grave disability” standard to clarify that the risk of harm to oneself includes the inability to take care of “basic needs,” of food, clothing, and shelter.
Nevertheless, the grave disability standard should not be conflated with the idea of “homelessness-as-pathology.”[lxxvii] The fact of homelessness itself, even for individuals with serious mental illness, does not mean that mental illness produced the condition of homelessness, or that the homeless individual poses a risk of harm to themselves or others.
Legal Standards
In New York, the standards for involuntary removal and involuntary commitment are governed by Article 9 of Mental Hygiene Law (MHL), which establishes relevant definitions and outlines procedures for the involuntary admission of individuals to psychiatric facilities.
These procedures apply to individuals on the basis of iterations of: appearing to be mentally ill and demonstrating behavior that is likely to result in harm to self or others.
Until August 7, 2025 (the effective date of the relevant FY 26 Budget amendments), in New York State, this likelihood of harm is defined as:
“(a) a substantial risk of physical harm to the person as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that the person is dangerous to himself or herself, or (b) a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm.” (MHL §§ 9.01)
The FY 26 Enacted Budget modifies this language, effective as of August 7, 2025, with the following significant addition:
“1. a substantial risk of physical harm to the person as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that the person is dangerous to themself, or 2. a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm, or 3. a substantial risk of physical harm to the person due to an inability or refusal, as a result of their mental illness, to provide for their own essential needs such as food, clothing, necessary medical care, personal safety, or shelter.” [Emphasis added.]
The statute also discretely defines the term “in need of care and treatment,” meaning having “a mental illness for which inpatient care and treatment in a hospital is appropriate.” It separately defines “in need of involuntary care and treatment,” as having “a mental illness for which care and treatment as a patient in a hospital is essential to such person's welfare and whose judgment is so impaired that he is unable to understand the need for such care and treatment.” (MHL §§ 9.01(a) and (b))
Due process rights
Patients subject to involuntary hospitalization retain important due process rights. If a patient or their representative believes that hospitalization is unnecessary, they may request a court hearing to challenge the admission. Continued retention in a hospital must be periodically reviewed and authorized by the court. Involuntarily admitted individuals also have the right to object to specific treatments and to seek legal and judicial review, particularly when treatment is administered over their objection.[lxxviii]
Process for Involuntary Removals and Admissions
Inpatient civil commitment can affect a broad range of individuals, including those experiencing one-time crises with no documented mental health history. Depending on the statutory pathway, any of several parties may raise the need for removal, which is then formally petitioned and certified by various professionals through legal application and clinical evaluation processes described later.
Broadly, though, individuals are typically identified for potential removal by people they reside with, family members, police, clinicians, and, in New York City, co-response teams (e.g., Partnership Assistance with Transit Homelessness (PATH), which was responsible for 144 involuntary transports in its first six months of operation,[lxxix] and Subway Co-response Outreach (SCOUT), which was responsible for 16 involuntary transports in 2024).[lxxx]
The following graphic, Figure 2 in the Treatment Advocacy Center’s 2020 Report, “Grading the States: An analysis of U.S. Psychiatric Treatment Laws,” demonstrates one common path through emergency removal, inpatient commitment, and AOT. Although it does not comprehensively reflect every potential path to involuntary treatment, it is helpful for visualizing some of the key steps in a linear way:
Emergency and involuntary removals
Section 9.37: authorizes county (or NYC) Directors of Community Services, or their designees, to make a formal application to the New York State Office of Mental Health (NYS OMH) for an involuntary removal. The standard for removal is that the affected person, in the opinion of the director of community services or the director's designee, has a mental illness for which immediate inpatient care and treatment in a hospital is appropriate and which is likely to result in serious harm to himself or herself or others (NB: as of August 2025, this will include the grave disability standard described earlier).
Upon the DCS's request, peace officers or police, with the option of ambulance services, are responsible for transporting the individual safely to the hospital.
Section 9.41: authorizes any peace officer or police officer to take into custody any person who appears to be mentally ill and behaving in a manner likely to result in serious harm to the person or others and transport them to a hospital or Comprehensive Psychiatric Emergency Program, immediately notifying the DCS accordingly.
Effective August 7, 2025, the statute is modified slightly on account of the addition of grave disability criteria to the section 9.01 definition of likelihood of harm:
“a peace officer or police officer directing the removal of a person who is conducting themself in a manner which is likely to result in serious harm as defined by paragraph three of subdivision (c) of section 9.01 of this chapter [i.e., grave disability language incorporated through the FY 26 Budget process], shall request the transport of such person be conducted by emergency medical services, if practicable based on: the person's potential medical needs and the capacity limits of the local emergency medical services agencies, as determined by the local emergency medical services agencies; and the safety of the person being removed, as determined by the officer.”
Section 9.43: allows anyone to submit a verified statement to the court, requesting that the judge issue a warrant for a person to be brought before the court and, at the judge’s discretion, is either dismissed (i.e., not in need of evaluation) or transported by law enforcement to a hospital for psychiatric evaluation.
Section 9.45: authorizes directors of community services (i.e., local mental health departments) or their designees to direct involuntary removal based on reports from certain parties[6] that a person has a mental illness for which immediate care and treatment is appropriate and which is likely to result in serious harm to self or others. A person who is the subject of this removal can, under certain circumstances, be transported to a crisis stabilization center instead.
Section 9.57: allows hospital directors to, at the request of emergency physicians, direct police to remove a patient to a 9.39 hospital or, until July 1, 2027, to a CPEP.[7] This is typically used in emergency settings of facilities that do not have inpatient psychiatric units.
Section 9.58: authorizes physicians and qualified mental health professionals who are part of a mobile crisis team to initiate the transport (by peace or police officers) of individuals who appear to be mentally ill and likely to cause serious harm to themselves or others, either to a hospital or a crisis stabilization center.
Once an individual has been “removed,” the process for involuntary commitment involves an initial emergency examination by a mental health professional and, if necessary, the individual may be temporarily admitted to a psychiatric facility for up to 72 hours (MHL § 9.40).
If the person requires longer treatment, a court hearing is scheduled within the 72-hour period to determine whether the individual meets the criteria for continued involuntary commitment. If the court finds that the individual meets the statutory criteria, the person may be committed for up to 60 days. Subsequent hearings are required to extend this commitment, with reviews at least every 90 days for ongoing involuntary hospitalization (MHL § 9.35). Throughout the process, individuals are afforded the right to legal representation and can challenge the commitment in court.
Note: It is also the case that individuals may become candidates for involuntary admission without moving through one of the removal pathways above. For example, an individual who attempts suicide and is hospitalized to physically recover could still be subject to involuntary admission beyond their initial medical visit (if they do not agree to voluntary hospitalization), through one of the routes described below.[lxxxi]
Emergency and involuntary admissions
1. Route by medical certification, or “two PC,” as authorized in MHL § 9.27.
Any of eleven specified parties[lxxxii] can initiate this admission process. Until the changes effectuated through FY 26 budget negotiations, the law required that, at the point of admission, two physicians must certify that the individual “has a mental illness for which care and treatment as a patient in a hospital is essential to such person's welfare and whose judgment is so impaired that the person is unable to understand the need for such care and treatment,” per MHL § 9.01.
The FY 26 Enacted Budget adjusted MHL § 9.27 to allow certification by an “examining physician and a psychiatric nurse practitioner,”[lxxxiii] together referred to as “certifying practitioners.” The shorthand of “two PC,” then, now means two “practitioners,” rather than two physicians.
NYS OMH has long included on the relevant application forms (i.e., 471 and 471A) that additionally, as a result of the individual’s mental illness, they must pose a substantial threat of harm to self or others (“substantial threat of harm” may encompass (i) the person’s refusal or inability to meet his or her essential need for food, shelter, clothing, or health care, or (ii) the person’s history of dangerous conduct associated with noncompliance with mental health treatment programs).
Once an individual is at the hospital, a staff psychiatrist, who must not be one of the two certifying practitioners who initially certified the admission, conducts a further examination to confirm that the individual meets the involuntary standard.
The patient (or the patient's representative) also has the right to demand a judicial hearing to challenge the commitment. Such a hearing must be held within five days of receipt of the request. A judge will hear evidence, often with Mental Hygiene Legal Services (MHLS), a state agency within the New York State Unified Court System, providing legal representation to the patient, and decide whether the involuntary commitment standard is met.
The patient can initially be held for up to 60 days. If they seek release during this period and the court denies their application, they can be held either for the remainder of the 60-day commitment or for up to 30 days after the denial of their release application, whichever is longer. If the hospital’s director determines continued involuntary care is necessary beyond 60 days, the director must apply for a court order of retention. The court must then verify that the individual still meets the involuntary standard as per MHL § 9.33 to approve further detention, which cannot exceed six months.
2. Route by Director of Community Services or Designee, as authorized in MHL § 9.37.
In addition to authorizing police and peace officers’ removal of individuals at DCS request, MHL § 9.37 further describes a process for involuntary admission for an individual who “has a mental illness for which immediate inpatient care and treatment in a hospital is appropriate and which is likely to result in serious harm to themself or others.”
Effective July 1, 2027, "likelihood of serious harm" will mean: “1. substantial risk of physical harm to themself as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that they are dangerous to themself, or 2. a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear or serious physical harm, or, 3. a substantial risk of physical harm to the person due to an inability or refusal, as a result of their mental illness, to provide for their own essential needs such as food, clothing, necessary medical care, personal safety, or shelter.”
Once the individual is at the hospital, a hospital staff physician must confirm the need for immediate involuntary admission within 24 hours using Form OMH 475C, which elicits the main information about eligibility for admission.[8] Within 72 hours of admission, excluding Sundays and holidays, a staff psychiatrist must further evaluate and certify the individual's need for immediate hospitalization using Form OMH 475D.
If extended care is necessary beyond the initial 60 days, the hospital must seek a court order of retention by demonstrating ongoing compliance with MHL § 9.33 criteria for involuntary admission.
3. Route by emergency admission, as authorized in MHL § 9.39. Other sections of statute are relevant (i.e., 9.40, 9.41, 9.43, 9.45, 9.55, 9.57, and 9.58).
The emergency standard allows for involuntary admission of individuals when there is "reasonable cause to believe that the person has a mental illness for which immediate observation, care, and treatment in a hospital is appropriate and which is likely to result in serious harm to himself/herself or others." This standard necessitates timely hospital intervention based on an immediate potential for harm.
This admission process does not require a formal application and can be initiated by various authorized entities, including peace or police officers, the court, the Director of Community Services (DCS), and qualified mental health professionals.
Once the individual is at the hospital, a staff physician must examine the person and determine whether their admission is appropriate under section 9.39. Within 48 hours of admission, the patient must undergo an evaluation by a staff psychiatrist, who must confirm the admitting physician’s determination of appropriateness for admission under section 9.39. These determinations are both documented on OMH Form 474.
Upon admission on an emergency basis, a patient, relative, friend, or Mental Hygiene Legal Services may request a court hearing (on their need for immediate observation, care, and treatment) in writing, which must occur within five days unless adjourned at the patient's request. The court will determine if there is reasonable cause to continue detention for up to 15 days or order release if such cause isn't found.
Although the initial hospital stay is capped at 15 days, it can be extended if the patient continues to meet criteria for involuntary admission per medical certification, at which point they are converted to a § 9.27 admission. At that point, their 60-day commitment period is calculated to begin from the date of initial emergency admission, per MHL § 9.39(b).
4. Route by Comprehensive Psychiatric Emergency Program (CPEP) emergency admission, as authorized in MHL § 9.40. Other sections of statute are relevant (i.e., 9.41, 9.43, 9.45, 9.55, 9.57, and 9.58).
The CPEP Emergency standard facilitates the involuntary admission of individuals when there is "reasonable cause to believe that the person may have a mental illness for which immediate observation, care, and treatment in a CPEP is appropriate and which is likely to result in serious harm to himself/herself or others." This standard specifically defines "likelihood of serious harm" to include a substantial risk of physical harm to the person, indicated by suicidal threats or behaviors, or a risk to others, shown by homicidal or violent behaviors that reasonably instill fear of serious physical harm.
Admission can be initiated without a formal application by the same parties eligible under the emergency standard of MHL § 9.39. Police and peace officers or an ambulance may transport an individual to a CPEP.
At the CPEP, a staff physician must assess the individual within 6 hours of arrival to determine if they meet the admission standard. Within 24 hours, another staff psychiatrist must confirm the initial assessment. If confirmed, the patient is moved to an extended observation bed (EOB),[lxxxiv] for up to 72 hours. Individuals are entitled to the option for a hearing on the need for immediate observation, care, and treatment, as in the emergency admission circumstance, above.
Beyond the initial 72-hour admission, discharge is required unless the patient meets the criteria for a longer involuntary hold under § 9.27 (for 60 days) or § 9.39 (for 15 days) and is admitted to a hospital on either basis. Any subsequent commitment periods—60 days under § 9.27 or 15 days under § 9.39—begin from the time the patient was first received in the CPEP.[lxxxv]
The following diagram, from NYS OMH’s Guidance on 14 NYCRR Part 590 “Comprehensive Psychiatric Emergency Programs” visualizes the workflow of the CPEP model and indicates
at which junctures involuntary care may occur:[lxxxvi]
Data Regarding Removals in New York City
Unfortunately, data on the number of involuntary transports (i.e., removals) and inpatient admissions statewide are scarce. In January 2025, the New York City Mayor’s Office of Community Mental Health (OCMH) published an annual report of involuntary transports for 2024.[lxxxvii] Some of the figures provided in the OCMH report are useful for orientation to the approximate utilization of the involuntary removal process, but there are considerable limitations, some of which the NYC Council identified in a report[lxxxviii] it issued in response.
The OCMH report is limited to transports authorized in New York City under MHL § 9.41 (police or peace officer initiated) and 9.58 (mobile crisis physician or other mobile crisis mental health professional initiated), which, even together, are not fully representative of the involuntary removal landscape.
Despite the Mayor’s November 2022 involuntary removal protocol, which recognized grave disability, this report from 2025 defines the standard for involuntary removal as strictly: (1) the person appears to be mentally ill; and (2) the person is behaving in a manner that presents a risk of serious harm to the person or others.[lxxxix]
There is no way to track removals of unique individuals, only the number of removals, which likely include multiple removals of the same individual.
The report explains: “Data for how many unique individuals have been involuntarily transported is not available, as responding clinicians and officers are unable to gather personal and biographical information of each person, as they are often in the middle of a mental health crisis.”
Given the ubiquity of multiple psychiatric crises and hospitalizations among individuals with unmanaged serious mental illness, efforts should be made to identify multiple removals of the same individual.
The racial data are considerably flawed; they rely on perceived race and merge “Hispanic” with either Black or white race.
The report explains: “Local Law 116 calls for the City to report data on the age, gender, race, ethnicity, and living situation of persons subject to involuntary transport. However, individuals in the midst of a mental health crisis are often unable to share such details before or while being transported. For personnel effectuating transports, the need to complete their task safely and quickly must take precedence over the collection of biographical information. Accordingly, much of the biographical data reported are unverified impressions of the officer or clinician and may be incomplete, inaccurate, and/or inconsistent with how the person being transported self-identifies.”[xc]
As above, efforts should be made to resolve these data gaps, even retroactively, to improve our understanding of equity issues in this system of care.
Data on NYC Health + Hospitals admissions are only available for involuntary transfers initiated by a clinician who has informed NYC Health + Hospitals, although, as the NYC Council report points out, NYPD-initiated involuntary transports are 10 times more likely.[xci]
Additionally, information on outcomes is only available for those transported to the City’s public hospitals and unavailable for those brought to private hospitals.
These limitations aside, the report found that there were 7,060 officer-initiated transports (i.e., MHL § 9.41) in 2024, according to NYPD and MTA PD data, and 661 clinician-initiated transports (i.e., MHL § 9.58) in 2024, according to NYC Department of Health and Mental Hygiene (DOHMH) and NYC Department of Social Services (DSS) data, with a three-month reporting lag. Of transports initiated by a clinician (i.e., of a mobile crisis team), 42% were not admitted; 58% of patients were admitted to inpatient treatment. The comparable statistic for officer-initiated transports is not available.
Although the debate regarding involuntary removals and involuntary commitment may create the impression that most removals come from the subway or other public spaces, the majority of removals were from private dwellings, which includes transitional housing, then other/unknown, then public transit, then public space.
The graph below presents the number of involuntary transports by location type:
New York City Councilmembers have cited the finding that five times more people were transported from private homes than public spaces to challenge the idea that this intervention is aimed at responding to individuals with mental health challenges in public spaces and transit.[xcii]
Statutory Interpretations and Changes
In the last few years, New York’s elected officials have intensely debated the merits and risks of changing civil commitment standards and approaches to individuals with serious mental illness who pose risks of harm or have already done harm to themselves or others. It is useful to recognize, however, that this issue has been revisited repeatedly during previous New York City mayoral administrations,[xciii] particularly in the late 1980s. Save for the opening clause, a New York Times article from that period could be confused for an article from today, some 30 years later:
“Beginning in October [1987], [Mayor Ed Koch] said, homeless people 'in danger of serious harm within the reasonably foreseeable future' will be taken to Bellevue Hospital for a 15-day examination. … Under the new policy, homeless people will be interviewed on the streets by a team of experts, including a psychiatrist, who will determine whether they should be taken to Bellevue. Once there, doctors will have to concur with the team's evaluation before a homeless person can be placed in a special 28-bed unit. Within 48 hours, a third doctor must agree that the person needs continuing care….The teams of city officials making the determinations on involuntary hospitalization will be members of the Health and Hospitals Corporation's Project Help. The group was established in 1982 to assist homeless people who do not enter the city's shelters. Two teams, which include a psychiatrist, a nurse and a social worker, seek out needy individuals.”[xciv]
Some have argued that the law has long allowed for more generous interpretations of dangerousness or harm, akin to the grave disability standard:
“Beginning in 1984, Koch declared that if temperatures dropped to below 5 degrees, including windchill, the police were authorized to remove individuals from public spaces and bring them to shelters, or, if they refused, hospitals. Such policies were arguably unnecessary, since the state law already allowed for involuntary commitment of individuals likely to cause serious harm to themselves or others. Yet each subsequent year, Koch broadened this policy, first to authorize police to act when the temperature dropped below freezing, then to anytime they believed an individual was in 'imminent danger,' And then in 1987 to when an individual was 'incapable of taking care of themselves.'”[xcv]
In February 2022, NYS OMH issued “Interpretative Guidance for the Involuntary and Custodial Transportation of Individuals for Emergency Assessments and for Emergency and Involuntary Inpatient Psychiatric Admissions,”[xcvi] which recognized criteria that include a “basic needs” standard. Notably, the forms required for application for involuntary inpatient admission explicitly include “the person’s refusal or inability to meet his or her essential need for food, shelter, clothing or health care” in the definition of substantial threat of harm to self or others.[xcvii] (Emphasis added)
Dr. Ann Sullivan, Commissioner of NYS OMH, has given clear examples of appropriate use of the criteria formally articulated in the 2022 memo, such as for a person “living on the street who had cellulitis in their leg, a serious infection that if left untreated could require the leg to be amputated, but who refused to go to the emergency room because they insisted that there was nothing wrong.”[xcviii]
Later in 2022, the administration of Mayor Eric Adams issued a memo that, by citing the “basic needs” standard, essentially communicated the City’s affirmation of the NYS OMH memo:
“Case law does not provide extensive guidance regarding removals for mental health evaluations based on short interactions in the field. But it does suggest that the following circumstances could be reasonable indicia of an inability to support basic needs due to mental illness that poses harm to the individual: serious untreated physical injury, unawareness or delusional misapprehension of surroundings, or unawareness or delusional misapprehension of physical condition or health.”[xcix]
The FY 26 New York State Enacted Budget has now codified the “basic needs” criteria for involuntary removals and inpatient civil commitment. Specifically, the definition of “likelihood to result in serious harm” in MHL § 9.01 will now include those at substantial risk of physical harm because their mental illness makes them unable or unwilling “to provide for their own essential needs such as food, clothing, necessary medical care, personal safety, or shelter” due to their mental illness. Many in public psychiatry leadership have endorsed the legal change as a means of helping to standardize clinical decision-making with more certainty than what case law has offered to date.
The Enacted Budget also added a section, MHL 9.64, to require hospitals and CPEPs to notify an individual’s community mental health provider(s) if the individual is admitted to these facilities.
Recommendations Regarding Involuntary Removals and Inpatient Civil Commitment
Given the recency of these State-level changes, this paper will not raise additional challenges and policy recommendations on the topic of involuntary removals and inpatient civil commitment, but will summarize a few items identified earlier in this section:
Data collection and reporting on involuntary transports and admissions must be timely, transparent, and standardized. Accurate data are operationally important for understanding how recent legislative changes impact volume for first response services and hospitals, which could inform how the State and New York City respond to resource needs. Further, being able to identify whether a particular individual has been involuntarily transported multiple times and under what circumstances would be valuable to the clinicians and human service providers trying to coordinate their care.
Codifying the legal changes presented in this section does not, in itself, resolve the revolving door problem. The State and New York City must continue to collaborate with and support providers of mental health and human services (e.g., hospitals, outpatient providers, mobile teams) in complying with regulations and guidance designed to hold all parties accountable and keep individuals from falling through the cracks. This includes efforts to identify when and why hospitals decline admissions for individuals who should meet criteria for that level of care.
Appendix
The following table presents data from the NYS OMH public AOT dashboard as of June 1, 2025, averaged statewide and in NYC:
Footnotes
[1] Each of the five NYS OMH regions (i.e., New York City, Long Island, Hudson River, Western, and Central) has an AOT Regional Coordinator who is appointed by the agency’s Commissioner.
[2] In NYC, care coordination is provided through the Health Home model if the individual has Medicaid coverage, or, if in NYC and not covered by Medicaid, through “non-Medicaid care coordination” (NMCC) through DOHMH.
[3] Note that criteria for renewal are not identical to criteria for initial AOT: per MHL §9.60(k)(2), individuals do not need to re-satisfy the criteria for past hospitalization or violence in certain time frames, as established in MHL §9.60(c)(4). See: Director of Community Services (DCS) Review and Determination of AOT Non-Renewal Guidance.
[4] In a related issue, Veterans Affairs (VA) does not recognize the authority of an AOT order and will not share information about care provided through the VA unless the individual consents.
[5] There are many undesirable effects associated with drugs commonly used to treat various mental illnesses. Ideally, individuals involuntarily committed should not merely have their symptoms and, in turn, dangerousness to self or others resolved, but also be guided to a regimen that will be sustainable beyond their hospitalization.
[6] Parties include: the individual’s parent, adult sibling, spouse, domestic partner, child, or legal guardian, a licensed psychologist, registered professional nurse or certified social worker currently responsible for providing treatment services to the person, a supportive or intensive case manager currently assigned to the person through certain NYS OMH-approved care management programs, a licensed physician, health officer, peace officer or police officer.
[7] Effective July 1, 2027, MHL § 9.57, “Emergency admissions for immediate observation, care and treatment; powers of emergency room physicians” will no longer mention CPEP.
[8] See 9.37(c) for exceptional considerations for counties with populations <200,000 and considerable distance to 9.39 facilities.
Endnotes
[i] Warburton, K., McDermott, B. E., Gale, A., & Stahl, S. M. (2020). A survey of national trends in psychiatric patients found incompetent to stand trial: Reasons for the reinstitutionalization of people with serious mental illness in the United States. CNS Spectrums, 25(2), 245-251.
[ii] Rankin, S.K. (2021). Hiding Homelessness: The Transcarceration of Homelessness. California Law Review, 109(2), 559–613.
[iii] Holtzman, B. (2021). The Long Crisis: New York City and the Path to Neoliberalism. Oxford University Press. p. 202.
[iv] Swanson JW, Swartz MS, Van Dorn RA, et al. (2006). A National Study of Violent Behavior in Persons With Schizophrenia. Arch Gen Psychiatry. 63(5):490–499.
[v] DeAngelis, T. (2021). Mental illness and violence: Debunking myths, addressing realities. APA Monitor on Psychology, 31–36.
[vi] Swanson JW, Swartz MS, Van Dorn RA, et al. A National Study of Violent Behavior in Persons With Schizophrenia. Arch Gen Psychiatry. 2006;63(5):490–499. doi:10.1001/archpsyc.63.5.490
[vii] Van Dorn, R., Volavka, J., & Johnson, N. (2012). Mental disorder and violence: is there a relationship beyond substance use?. Social psychiatry and psychiatric epidemiology, 47, 487-503.
[viii] Martell, D. A., & Dietz, P. E. (1992). Mentally disordered offenders who push or attempt to push victims onto subway tracks in New York City. Archives of general psychiatry, 49(6), 472-475.
[ix] Bisram, J. (2025, January 14). With NYC subway safety in the spotlight, Michelle Go’s father speaks out 3 years after deadly shoving incident. CBS New York.
[x] Labrum, T., Zingman, M. A., Nossel, I., & Dixon, L. (2021). Violence by Persons with Serious Mental Illness Toward Family Caregivers and Other Relatives: A Review. Harvard Review of Psychiatry, 29(1), 10–19.
[xi] New York City Mayor’s Office of Community Mental Health. (2025, January 31). 2024 Annual Report of Involuntary Transports. Presented to NYC City Council (Local Law 116 2023). p. 9.
[xii] Fusar‐Poli, P., Correll, C. U., Arango, C., Berk, M., Patel, V., & Ioannidis, J. P. (2021). Preventive psychiatry: a blueprint for improving the mental health of young people. World Psychiatry, 20(2), 200-221.
[xiii] Labrum, T., Zingman, M. A., Nossel, I., & Dixon, L. (2021). Violence by Persons with Serious Mental Illness Toward Family Caregivers and Other Relatives: A Review. Harvard Review of Psychiatry, 29(1), 10–19.
[xiv] Dailey, L., Gray, M., Johnson, B., Muhammad, S., & Sinclair, E. (2020). Grading the States: An Analysis of Involuntary Psychiatric Treatment Laws. Treatment Advocacy Center.
[xv] New York State Office of Mental Health. Assisted Outpatient Treatment Frequently Asked Questions: Procedural Questions.
[xvi] New York State Office of Mental Health. (2024, August 6). Response Letter to Audit Director of the Office of the State Comptroller. p. 2.
[xvii] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xviii] Hancq, E. S., Munetz, M., Silver, S. C., Parker, H. A., & Bonfine, N. (2024). Critical Gaps in Assisted Outpatient Treatment Research in the United States. Administration and Policy in Mental Health and Mental Health Services Research, 51(6), 839–842.
[xix] New York State Office of Mental Health. (2021, September). Assisted Outpatient Treatment Program: Guidance for AOT Program Operation. See p. 2.
[xx] Division of State Government Accountability. (2024). Office of Mental Health: Oversight of Kendra’s Law (Audit Report 2022-S-43). Office of the New York State Comptroller. p. 14.
[xxi] Colton, J., Misra, R., Woznick, E., Wiedermann, R., & Huh, A. (2024). Reaching the Unreachable: Intensive Mobile Treatment, an Innovative Model of Community Mental Health Engagement and Treatment. Community Mental Health Journal, 60(5), 839–850.
[xxii] New York State Office of Mental Health. Specialty Mental Health Care Management Agency Attestation to Serve Health Home Plus Individuals with Serious Mental Illness.
[xxiii] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xxiv] New York State Office of Mental Health. (2025, June 9). Access to care: Tableau reports.
[xxv] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xxvi] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xxvii] Meltzer, HY. Treatment-resistant schizophrenia–the role of clozapine. Curr Med Res Opin. 1997;14(1):1–20.
[xxviii] Howes, O. D., Thase, M. E., & Pillinger, T. (2022). Treatment resistance in psychiatry: state of the art and new directions. Molecular Psychiatry, 27(1), 58-72.
[xxix] New York State Office of Mental Health. Guidelines for Initial Reporting by Local Governmental Units (LGUs) on Assisted Outpatient Treatment (AOT).
[xxx] Seigerman, M. (2024, July 31). Assisted Outpatient Treatment Training [Webinar]. New York City Department of Health and Mental Health. See: 30:49.
[xxxi] Seigerman, M. (2024, July 31). Assisted Outpatient Treatment Training [Webinar]. New York City Department of Health and Mental Health. See: 31:45.
[xxxii] New York State Office of Mental Health. (February 2014). Guidance for Reporting Significant Events.
[xxxiii] New York State Office of Mental Health. (February 2014). Guidance for Reporting Significant Events.
[xxxiv] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xxxv] New York State Unified Court System. Guardian Assistance Network. Resources for Mental Illness/ Assisted Outpatient Treatment: Non-Compliance with an Order of Assisted Outpatient Treatment.
[xxxvi] New York State Office of Mental Health. (2025, May 30). AOT Recipient Outcomes: Significant Events: Homelessness.
[xxxvii] Office of the New York State Comptroller: Division of State Government Accountability. (February 2024). Office of Mental Health: Oversight of Kendra’s Law (Audit Report 2022-S-43).
[xxxviii] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xxxix] Office of the New York State Comptroller: Division of State Government Accountability. (February 2024). Office of Mental Health: Oversight of Kendra’s Law (Audit Report 2022-S-43). p. 18.
[xl] New York State Office of Mental Health. (2025, May 30). AOT Recipient Outcomes: Reasons for Non-Renewal of Court Orders.
[xli] New York State Office of Mental Health and New York State Office for People with Developmental Disabilities. New York Secure Ammunition and Firearms Enforcement Act (NY SAFE Act): Guidance Document.
[xlii] New York State Office of Mental Health. (2017, May 11). Kendra’s Law – A Fresh New Look [Webinar].
[xliii] Harris, A. J., & Ransom, J. (2024, February 8). Audit Finds Fatal Lapses in Mental Health Program Meant to Curb Violence. The New York Times.
[xliv] Office of the New York State Comptroller: Division of State Government Accountability. (February 2024). Office of Mental Health: Oversight of Kendra’s Law (Audit Report 2022-S-43).
[xlv] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xlvi] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[xlvii] Geringer-Sameth, E. (2022, September 27). What’s Behind the Increased Use of Kendra’s Law in New York City? Gotham Gazette.
[xlviii] Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., & Robbins, P. C. (2001). Assessing the New York City Involuntary Outpatient Commitment Pilot Program. Psychiatric Services, 52(3), 330–336.
[xlix] Phelan, J. C., Sinkewicz, M., Castille, D. M., Huz, S., & Link, B. G. (2010). Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State. Psychiatric Services, 61(2), 137–143.
[l] Swartz, M. S., Swanson, J. W., Steadman, H. J., Robbins, P. C., & Monahan, J. (2009). New York State Assisted Outpatient Treatment Program Evaluation. (2009, June 30). Duke University School of Medicine, Policy Research Associates, and University of Virginia School of Law.
[li] Arati Prabhakar & Susan E. Rice. (2023). White House Report on Mental Health Research Priorities. The White House. p. 17.
[lii] New York State Office of Mental Health. (2023). Evaluation of the New York State Assisted Outpatient Treatment Program.
[liii] Gonzales, L., Nesi, D., & Yanos, P. T. (2015). An Examination of Eligibility Decisions in New York State’s Assisted Outpatient Treatment. Psychiatric Services, 66(12), 1373–1376.
[liv] Hancq, E. S., Munetz, M., Silver, S. C., Parker, H. A., & Bonfine, N. (2024). Critical gaps in assisted outpatient treatment research in the United States. Administration and Policy in Mental Health and Mental Health Services Research, 51(6), 839-842. p. 841.
[lv] New York State Office of the Governor. (2025, May 9). Governor Hochul Signs Legislation to Improve Mental Health Care and Strengthen Treatment for Serious Mental Illness as Part of FY 2026 Budget.
[lvi] Harris, A. J., & Ransom, J. (2024, February 8). Audit Finds Fatal Lapses in Mental Health Program Meant to Curb Violence. The New York Times.
[lvii] New York State Office of Mental Health. (2024, August 6). Response Letter to Audit Director of the Office of the State Comptroller.
[lviii] Office of the New York State Comptroller: Division of State Government Accountability. (February 2024). Office of Mental Health: Oversight of Kendra’s Law (Audit Report 2022-S-43).
[lix] In re Miguel M, 950 N.E. 2d 107 (N.Y. 2011)
[lx] Gomez, A. and Knight, S.C. (2013). Disclosure of Mental Health Records in Court-Mandated Outpatient Treatment Proceedings and the Health Insurance Portability and Accountability Act (HIPAA). Journal of the American Academy of Psychiatry and the Law Online, 41(3), 460–461.
[lxi] Fisher, W. (2024, October 17). AOT in NYC: An Overview [Webinar]. AOT Learning Network. Treatment Advocacy Center.
[lxii] New York State Office of Mental Health. (2025, January 9). Response Letter to Senators Krueger and Hoylman-Sigal.
[lxiii] New York State Office of Mental Health and New York State Department of Health. (October 2023). Guidance on Evaluation and Discharge Practices for Comprehensive Psychiatric Emergency Programs (CPEP) and §9.39 Emergency Departments (ED). p. 8.
[lxiv] New York State Office of Mental Health. (2023, April 21). OMH NIMRS Definitions For Incident Types And Reportability.
[lxv] Troy Boyle. (2025, March 31). Hochul’s proposed mental health reforms offer real solutions. Empire Report.
[lxvi] Lewis, C. (2025, March 24). NYC Council press officials to cut wait times for mobile mental health teams. Gothamist.
[lxvii] New York State Office of Mental Health. (February 2014). Assisted Outpatient Treatment Program Guidance for AOT Program Operation.
[lxviii] Office of the New York City Comptroller Brad Lander. (2025, January 13). Safer for All.
[lxix] Avellaneda-Ojeda, A., Murtaza, S., Shah, A. A., & Moukaddam, N. (2018). Stimulant use disorders. Psychiatric Annals, 48(8), 372-378.
[lxx] New York State FY 2026 Executive Budget: Health and Mental Hygiene Article VII Legislation. Part EE. p. 219.
[lxxi] Office of Behavioral Health, Disability, and Aging Policy. (2024). Assessing Level of Judicial Involvement in Assisted Outpatient Treatment. United States Department of Health and Human Services: Office of the Assistant Secretary for Planning and Evaluation.
[lxxii] Munetz, M. R., Ritter, C., Teller, J. L., & Bonfine, N. (2014). Mental health court and assisted outpatient treatment: Perceived coercion, procedural justice, and program impact. Psychiatric Services, 65(3), 352–358.
[lxxiii] Hancq, E. S., Munetz, M., Silver, S. C., Parker, H. A., & Bonfine, N. (2024). Critical Gaps in Assisted Outpatient Treatment Research in the United States. Administration and Policy in Mental Health and Mental Health Services Research, 51(6), 839–842.
[lxxiv] New York State Office of Mental Health. (2017, May 11). Kendra’s Law – A Fresh New Look [Webinar].
[lxxv] New York State Unified Court System. (2025, February 1). First Annual Report and Recommendations of the New York State Judicial Task Force on Mental Illness.
[lxxvi] Newman, A., Schweber, N., & Marcius, C. R. (2022, February 5). Decades Adrift in a Broken System, Then Charged in a Death on the Tracks. The New York Times.
[lxxvii] Holtzman, B. (2021). The Long Crisis: New York City and the Path to Neoliberalism. Oxford University Press. p. 348.
[lxxviii] New York State Office of Mental Health. Rights of Inpatients in New York State Office of Mental Health Psychiatric Centers.
[lxxix] Geringer-Sameth, E. (2025, March 24). Mental health homeless outreach pilot results in over 100 involuntary removals in first 6 months. Crain’s New York Business.
[lxxx] Metropolitan Transportation Authority. (2024, March 27). Subway Co-Response Outreach Teams: Presentation to the MTA Board.
[lxxxi] New York State Office of Mental Health. OMH Interpretative Guidance for Involuntary and Emergency Admissions Webinar Q&A.
[lxxxiii] New York State FY 2026 Executive Budget: Health and Mental Hygiene Article VII Legislation. Part EE.
[lxxxiv] New York State Office of Mental Health. (2021, September 1). 14 NYCRR Part 590: Comprehensive Psychiatric Emergency Programs.
[lxxxv] New York State Office of Mental Health. Mental Hygiene Law Admissions Process. See “*****.”
[lxxxvi] New York State Office of Mental Health. (2021, September 1). 14 NYCRR Part 590: Comprehensive Psychiatric Emergency Programs. p.40.
[lxxxvii] New York City Mayor’s Office of Community Mental Health (OCMH). (2025, January 31). 2024 Annual Report of Involuntary Transports. Presented to NYC City Council (Local Law 116 2023).
[lxxxviii] New York City Council. (2025, March 21). What the Data Shows about Mayor Adams’ Involuntary Removal Policy.
[lxxxix] New York City Mayor’s Office of Community Mental Health (OCMH). (2025, January 31). 2024 Annual Report of Involuntary Transports. Presented to NYC City Council (Local Law 116 2023). p. 3.
[xc] New York City Mayor’s Office of Community Mental Health (OCMH). (2025, January 31). 2024 Annual Report of Involuntary Transports. Presented to NYC City Council (Local Law 116 2023). p. 3.
[xci] New York City Council. (2025, March 21). What the Data Shows about Mayor Adams’ Involuntary Removal Policy. p. 3.
[xcii] New York City Council. (2025, March 21). What the Data Shows about Mayor Adams’ Involuntary Removal Policy. p.2.
[xciii] Sterne, P. (2025, March 31). New York has debated forced psychiatric treatment for decades. City & State New York.
[xciv] Daley, S. (1987, August 29). New York expands treatment policy for the homeless. The New York Times.
[xcv] Holtzman, B. (2021). The Long Crisis: New York City and the Path to Neoliberalism. Oxford University Press. p. 260. Note: There were many other local, political factors that account for changes in the volume and demographics of homeless individuals in New York City, especially those with mental illnesses. Chapter 6, “The Governance of Homelessness and Public Space” provides a robust summary of relevant policy choices, mayoral positions and initiatives, and the roles of public transit authorities and private companies in responding to rising homelessness.
[xcvi] New York State Office of Mental Health. (2022, February 18). Interpretative Guidance for the Involuntary and Custodial Transportation of Individuals for Emergency Assessments and for Emergency and Involuntary Inpatient Psychiatric Admissions.
[xcvii] New York State Office of Mental Health. “Form OMH 471: Application for Involuntary Admission on Medical Certification.” See Part B, p. 2. and “Form 475: Application for Involuntary Admission on Certificate of a Director of Community Services or Designee.” See Part 1.A., p. 1.
[xcviii] Sterne, P. (2025, March 31). New York has debated forced psychiatric treatment for decades. City & State New York.
[xcix] The Office of the Mayor: City of New York. (2022, November 29). Mayor Adams Announces Plan to Provide Care for Individuals Suffering From Untreated Severe Mental Illness.