Mayor Adams’ plan to establish a “culture of engagement” for unsheltered people with severe mental illness has been met with understandable scrutiny, but also a blizzard of misinterpretation. The New York Times headline announcing the initiative was “New York City to Involuntarily Remove Mentally Ill People From Streets,” leaving the impression the mayor would haul away thousands of homeless people against their will to cleanse the streets of them. Other coverage has been similarly histrionic and misleading.
In reality, the Adams plan consists of a few sensible measures narrowly focused on meeting the urgent needs of a small subset of the unsheltered whose mental illness places them in danger. Many suffer from anosognosia — a part of their brain disease that robs them of insight into their current grave condition. Often delusional, they resist voluntary treatment for diseases they don’t know they have and their symptoms, left untreated, become ever more ruinous.
One of us helped craft the Adams initiative. The other has lived experience with anosognosia, via a brilliant and talented son who had a psychotic break at age 24 which included no insight into his serious mental illness. What followed was ten years of Hell for him and his family, as his refusal to accept any treatment, in a broken mental health system that left his family powerless to help, led to deterioration and ultimately his death. Preventing such tragedies is a moral imperative and a responsibility of government the mayor has embraced.
His plan has five components:
• A directive to the city’s mobile crisis clinicians and first responders, clarifying the process for transporting an individual for hospital evaluation and amplifying longstanding New York case law which has recognized the legality of involuntary intervention when mental illness makes a person a danger to themselves by preventing them from meeting their basic needs of food, clothing, shelter, or medical care. The directive aims to conquer a pervasive myth, which too often thwarts care for people in obvious crisis, that the legal standard always requires an evident threat of violence, suicide or imminent harm. But this part of the directive is purely informative. In no way does it call for sweeps of public spaces or aggressive application of the “basic needs” criteria.
• Training enhancements in accordance with the new directive, designed to promote a deeper understanding among city personnel of the full scope of their authority to assist a person who appears unable to meet their basic needs due to mental illness. The training will stress the need to exhaust options to persuade the person to accept voluntary hospital transport before resorting to involuntary means.
• New co-responder teams pairing clinicians with police officers, dedicated to the difficult work of getting New Yorkers in crisis into care. These teams will allow clinicians to lead efforts to assess and establish rapport with persons encountered, and will have the training, expertise and sensitivity to ensure that those in need are safely transported to hospitals for evaluation.
• A new tele-consult line to make clinicians from city-operated hospitals available to police officers in the field, enabling officers to share their observations of individuals who may need assistance and receive advice on available resources and alternatives.
• A legislative agenda to address flaws and gaps in the New York Mental Hygiene Law which contribute to the city’s challenges in meeting the needs of individuals in psychiatric crisis. The agenda includes codifying the “inability to meet basic needs” criteria for involuntary intervention, as is already recognized in New York case law.
Contrary to reporting, the plan diminishes the current role of police officers in making assessments and interfacing with the unsheltered, and calls for people to be transported to hospitals in ambulances, not squad cars. It follows New York law requiring that the ultimate decision to admit for treatment be made by a hospital physician, not a cop, and supported by clear and convincing evidence if the person exercises their right to a court challenge.
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We understand concern over whether the city has enough inpatient psychiatric beds to make this work. It is undeniable that New York pressingly needs more such beds, with hundreds lost to the COVID crisis still unrestored. But predictions of a flood of new patients exacerbating this challenge are dubious. The actual number of unsheltered New Yorkers whose mental illness renders them unable to meet basic needs is smaller than their high visibility might suggest. If we leave them on the street untreated, most will eventually end up hospitalized anyway, because they will decompensate and come to qualify for admission as “dangerous” under any interpretation of the law, or they will be arrested and fall into the forensic treatment system. Rather than bring new people into hospitals, the mayor’s plan will mainly bring unavoidable patients in earlier, when treatment is likely to be more effective.
And news on the bed front is not all bad. Gov. Hochul recently announced 50 new extended-care beds for the city, each providing up to 120 days of inpatient treatment. The number may be modest relative to the entire current bed deficit, but it’s actually a significant help given the relatively few patients with that level of need. More bed breakthroughs are in the works.
Critics also assert hospitalization is pointless for the population the mayor seeks to help without more follow-up supports in place. Again, no argument from us on the burning needs, borne of decades of systemic neglect that the Adams administration is working diligently to reverse. Treatment cannot simply be 72 hours in a hospital and release back onto the streets. We must fortify our full continuum of care, including more clinicians and peer counselors, supportive housing, step-down programs, and the replication of clubhouses like Fountain House to foster community. And we need a concerted effort to decriminalize mental illness, with so many afflicted cycling in and out of jails and prisons.
But a critical point seems to have been missed: this plan is focused on people who we find in acute psychiatric crisis, failing to meet basic human needs. To walk away from someone in that wretched condition is unconscionable per se. At that moment, the one thing we know for sure is that psychosis will get worse, with terrible outcomes, if left to fester.
Holes in our safety net notwithstanding, it is surely better to stabilize the person’s condition through hospital care, identify their ongoing needs through discharge planning, and allow a decidedly imperfect system to work on connecting the person with appropriate existing resources. The cupboard is not as thoroughly barren as some imagine. Recovery is only impossible if we refuse to start with treating the active psychosis.
Unquestionably, the need for treatment must be balanced with respect for civil liberties. But anyone who has experienced the horror of seeing a loved one deteriorate, and die, because their brain disease went untreated, knows we have no choice but to find ways to get people help that they do not themselves recognize they need. This is a first step, and a good one.
Stettin is the Adams administration’s senior advisor on severe mental illness. Ornstein is a senior fellow emeritus at the American Enterprise Institute.
