Mayor Adams’s new initiative aimed at helping New Yorkers grappling with serious mental illness on our streets — including involuntarily hospitalizing them at times — might be the single most difficult effort of his administration. More than anything else he has attempted in his first year in office, it will test the mayor’s promise to cut through bureaucracy and successfully tackle problems that his predecessors failed to fix.
“I want these problems. I noticed them for years as a police officer, I saw how we abandoned people, and I made that commitment,” he told CNN host Michael Smerconish. “I ran towards gunshots as a cop. I’m going to run towards the problems we’re facing in the city that is leading to the dysfunction of our city.”
It’s commendable that the mayor is taking action. But the bold metaphor of a cop running toward danger raises the question: What happens next? A surprisingly complex set of obstacles pops up when one tries to help an obviously distressed person who is shouting at invisible antagonists, shadowboxing on the subway platform, or eating out of a trash can.
This is one of the rare instances where it might make sense for the mayor to appoint a blue-ribbon committee to draft a set of recommended actions.
“All of us, as New Yorkers, have seen people in need. And we’ve asked ourselves the question, ‘What can I do for this person? Who do I call? Where can I help?’ And we may not have known the answer,” Health Commissioner Ashwin Vasan told me recently. “This mayor is saying, ‘We’re not going to do that as a city. We’re going to stay, we’re going to engage. We’re going to do everything we can to get them to receive voluntary services. And in the event that they cannot, we’re going to take them to a place where they can get a full evaluation.’”
That can be a tall order: Complicated medical, legal, fiscal, and operational issues crop up immediately. Has the person’s apparent mental illness been diagnosed by a qualified medical professional? If so, who has the records? Is the behavior chronic or related to substance abuse? Does he need a place to stay? Is he a danger to himself or others?
And who is supposed to sort through all these issues and coordinate the alphabet soup of city and state agencies that might be engaged? Merely removing a disturbed but disruptive person from the subway system could easily involve the MTA, NYPD, EMS, the district attorney, Health & Hospitals, and the Department of Homeless Services.
There’s no clear, written plan on how Adams plans to navigate these thorny issues. And that has opened the door for several civil-rights organizations, unhappy about the language Adams is using, to take the city to federal court, seeking a restraining order to block any changes from taking effect. That opposition is surely premature in the absence of a detailed plan — but it’s a sign that the administration needs to tighten up its approach to the problem.
“It is a very complex system. When I was at the Health Department, we did convene all of the city agencies,” says Dr. Oxiris Barbot, the former city Health commissioner who now runs the United Hospital Fund. “It’s an example of how there are lots of well-meaning people trying to put their resources to good use. But when there’s lack of communication across agencies, across community organizations, there’s a lot of missed opportunities.”
Vasan agrees. “Let’s start with the acceptance that this is really hard. It’s very hard work to do, especially in the moment, to try to assess things like imminence of threat and all of these things. What we as doctors do is look at a person and we say, ‘Is that a person that seems to be hurting in some way, in need in some way, in pain in some way, unable to live a life that is by any shared definition dignified, and are there ways we can help?’ That’s all this is about.”
The good news, according to Dr. Mitchell Katz, the president of Health + Hospitals, is that the city’s 50 hospitals can handle the relatively small number of New Yorkers who will need the kind of intensive intervention Adams is calling for.
“I think it’s generally accepted that there are about 3,500 people in New York City who are homeless and living on the streets as opposed to in the shelter system,” Katz told me. “And of that, there’s probably about 1,000 who have a serious mental illness. And then it’s a much smaller number — who may be a couple of hundred — who are so distressed, and so incapable of seeing that distress, that they really need the help getting services because they turn it away.”
Katz, who helped organize the city’s heroic response to the COVID pandemic, is the kind of can-do leader who, like Adams, does not shy away from a challenge. But he and the mayor should recognize that the city needs a detailed plan for coping with the broken bureaucratic systems that reporter Maya Kaufman has described in Crain’s New York Business.
“Many hospitals refuse to admit seriously mentally ill patients, instead doling out medication to subdue their symptoms and immediately cutting them loose,” Kaufman reports. “Some keep lists of particularly violent patients who should be automatically transferred elsewhere. In academic literature, the vicious cycle has its own name: transinstitutionalization or the institutional circuit.”
Public Advocate Jumaane Williams has also been sounding a warning that the city needs to streamline its bureaucracy so that cops are not automatically dispatched first. He recently released a report detailing shortcomings in funding levels and deployment procedures when dealing with mentally ill New Yorkers.
“What we should not assume is that a mental-health call needs a police response, and that has been the problem from the beginning,” Williams says. “We actually need a different number that we’ve been pushing for” — a reference to 988 as a crisis mental-illness hotline where that’s more appropriate than dialing 911 — “so people can call to get the assistance that they need. We should not be asking police to make medical decisions, to involuntarily put someone in the hospital.”
What might seem like a simple, baseline citizen request — to help people who seem clearly in distress — has already led to a federal lawsuit, political jousting between the mayor and public advocate, and fears that bureaucracy will be too slow and clunky to help.
“I did not become the mayor to climb a hill. I became the mayor to climb a mountain,” Adams said on CNN.
Welcome to Mt. Everest, Mr. Mayor.