After de Blasio, will NYC’s mental health thrive?

Rigoberto Lopez had struggled with mental illness since he was a teenager. But what his relatives described as typical, rebellious adolescent behavior escalated as he got older. After turning 18, he left home, bouncing between relatives’ homes before entering New York City’s shelter system in May 2019. Then, as his drug addiction worsened, he started getting in trouble, his brother told The New York Times.

Within a few months, Lopez attacked his father with a stick after the man refused to give him money, then showed up at work to threaten him, according to news reports based on police accounts. Weeks later, he punched an officer in the face and spent four months in jail until his father paid bail in March 2020, just as the city went into lockdown. In the fall, Lopez was again arrested in Washington Heights with 48 bags of cocaine and a knife, after which a judge placed him under court-ordered supervision. During his string of arrests, he was taken to the hospital for psychiatric treatment, but each time was released after being held for a few days.

Lopez had skipped several court appearances and more than a dozen check-ins by February 12, when he went on a killing spree on the New York City subway. Over the course of 24 hours, Lopez stabbed two people to death on the A-line and seriously injured two others at the 181st Street Station before police apprehended him covered in blood with the murder weapon.

“I want people to know, we’re going to do whatever the hell it takes to keep subways safe,” said New York City Mayor Bill de Blasio, who dispatched 500 additional police officers to patrol the transit system.

Despite the influx of officers and the MTA’s still-depressed ridership, subway assaults have continued to rise, reaching a 23-year high in the first quarter of 2021. Within a few hours on one day in May, a 60-year-old woman was stabbed on the No. 3 line, another was hit in the face with a skateboard and a man was slashed with a knife.

As the number of vaccinated New Yorkers climbs and the streets and subways fill with crowds again, the city is only beginning to come to terms emotionally with the fallout from the pandemic. While the staggering death count of 33,000 and the 750,000 jobs lost in New York City are quantifiable, it is difficult to measure the effects on New Yorkers’ mental health. The pandemic upended lives through the isolation of lockdown and social distancing, unmet childcare needs, job loss, homelessness, or grief and anxiety over illness and death, leaving New Yorkers to deal with the repercussions. Americans across the country experienced similar hardships, but given its population density and status as the epicenter of the first major U.S. outbreak, New York has experienced an outsized share of the virus’s psychic toll.

“Everyone in New York has been affected by the pandemic, whether by financial insecurity, loss of loved ones, or uncertainty about the future,” said Susan Herman, director of the Mayor’s Office of Community Mental Health, formerly the Office of ThriveNYC. “It’s going to take some time to fully understand the impact the pandemic has had on mental health.”

However, the city hasn’t yet met its pre-Covid goal of addressing the underlying mental health needs of its citizens, which the next administration will have to pick up in the context of an ongoing crisis.

In 2015, two years into his first term, New York City Mayor Bill de Blasio made mental health a signature priority when he announced the creation of ThriveNYC, a series of 54 initiatives with a budget of $850 million over four years. Helmed by the mayor’s wife Chirlane McCray, the initiative morphed into the Office of ThriveNYC in January 2019. This May, it was moved into City Hall and made permanent as the Mayor’s Office of Community Mental Health.

The pandemic was nothing if not a major stress test for Thrive’s various programs and the city’s sprawling mental health infrastructure. The vast majority of people with mental illness are not prone to violence; the recent spate of subway attacks are only the most visible example of the City’s unmet needs. Most of the suffering caused by COVID-19 has occurred out of public view.

At the height of the lockdown in May 2020, more than one-third of state residents reported experiencing depression and anxiety because of the pandemic, according to the New York State Health Foundation. 70% of New Yorkers reported an increase in anxiety and stress between May and June. Calls to the city’s mental health hotline, NYC Well, jumped from 5,000 per week in 2019 to 6,000 per week in 2020.

These numbers reflect the traumatic experiences of the pandemic and its economic fallout. Unemployment jumped from just above 4% before COVID-19 hit to a high of 20% in June 2020. The number of shootings doubled in the city last year, while homicides jumped 45%. Homelessness among single adults grew by 10%, reaching a record high of 20,822 per night in February, according to the Coalition for the Homeless, a nonprofit advocacy organization. Around 4,200 of the city’s children lost a parent, and 325,000 more kids were pushed into poverty. As with nearly every other index of well-being, people of color and the poor suffered disproportionately, with 45% of white New Yorkers reporting income loss compared with 67% and 68% of Latino and Black residents, respectively.

Above all, COVID-19 exacerbated existing mental health inequalities. Those who lost jobs often lost insurance as well, leading to a dropoff in care; Zoom calls replaced in-person psychiatric visits; poor and homeless New Yorkers, who may lack consistent access to mobile phones and the Internet, lost contact with providers.

“Quite simply, we do not have mental health services available at a time when people are experiencing anxiety and depression at levels never experienced before,” said Matthew Shapiro, associate director of public affairs for New York at the National Alliance on Mental Illness. 

When ThriveNYC launched in November 2015, one of its primary goals was to “change the culture” around mental health. Public policy generally focuses on those in crisis, such as people who may harm themselves or others.

Gary Belkin, deputy health commissioner for New York City and chief of ThriveNYC from 2014 until 2018, said the initiative was intended to break past this narrow focus. “Only reaching the guy sleeping in the subway or woman screaming on the street corner leaves you stuck chasing crises,” Belkin said. “There is far more burden of disease in depressed mothers and suicidal kids and unemployed workers and distressed and traumatized neighborhoods than in people with schizophrenia.”

For Belkin, addressing mental health fully meant going beyond the traditional network of delivery, such as hospitals and clinics, to partner with community-based organizations, and connecting the efforts of an array of city agencies whose primary functions may not be related to mental health. Mental illness, he noted, is not only a health care problem but “an education problem, a police problem, a youth problem.”

ThriveNYC’s original launch plan, developed with the input of 200 organizations and backed by a scientific advisory group, listed six areas of focus, which included intervening early on mental health problems before they escalate, better coordinating the efforts of government agencies and nonprofits and using data to help close treatment gaps. Housed in the New York City Department of Health and Mental Hygiene, the program included 54 initiatives – 23 of them new, the rest existing programs – that ThriveNYC would support and oversee.

“We want New York City to be a place where people can live their lives to the fullest,” McCray said at the program’s launch. “ThriveNYC is about more services, better services and easier access to services.”

The plan’s marquee directives included a public-awareness campaign to decrease stigma and the creation of NYC Well, a mental health hotline, a year later. ThriveNYC also pledged to hire 400 clinicians to deploy in high-needs communities, bring 100 mental health “consultants” into public schools to better respond to students’ needs, and train 250,000 New Yorkers in mental health first aid.

In its first year, ThriveNYC directed $44 million – $35 million less than what was earmarked – across more than 15 city agencies, including $3.9 million on media. McCray went on a national publicity tour that included speaking with congressional leaders.

Nearly as soon as it launched, ThriveNYC attracted criticism from some experts who said it should focus on serious mental illnesses such as schizophrenia and more severe forms of bipolar disorder and major depression.

“The mayor dedicated over $2 million to an ad campaign trying to get people who have ‘anxiety, depression or need someone to talk to’ to call a referral line,” D.J. Jaffe, former executive director of the Mental Health Policy Org., wrote in the Daily News six months after ThriveNYC’s launch. “The ads don't ask those who are psychotic, delusional, and eating out of dumpsters to call.”

Manhattan Institute fellow Stephen Eide argues that for those with serious mental illness, social anxiety about seeking treatment is often less of an impediment to care than the symptoms of the illness itself. “There are many reasons why people don’t get access to quality care and stigma is relatively low down on that list when talking about seriously mentally ill people,” Eide said.

Statistics show that many of those with serious mental illness in New York City are not receiving care. While 87% of those eligible for the state’s Health and Recovery Plans – New York’s Medicaid plan for those with significant behavioral health needs – are enrolled, only about 3% accessed care in the last year. According to Jaffe’s organization, between 19% and 24% of ThriveNYC’s 2020 budget focused on those with serious mental illness.

Another frequent criticism of ThriveNYC, especially in the New York Post, was that the first lady, an unelected official, was handed the position through nepotism to raise her public profile. McCray does not have a background in mental health policy and has spent most of her career in communications. She has said in interviews that her own family’s struggles with mental illness inspired her to take on ThriveNYC.

In the first few years of ThriveNYC’s existence, McCray rolled out a series of initiatives including the Mental Health Service Corps, which dispatches clinicians to high-need communities; Sisters Thrive, which trains African American girls in psychiatric first aid; and a program to distribute kits of naloxone and buprenorphine to social-service agencies in case of an opioid overdose.

As McCray spoke about her signature program at conferences and events, her political aspirations became controversial. In March 2018, McCray told news outlets that she was considering a run for office. That same month, she appointed Alexis Confer, who helped create the mayor's universal pre-K program, as ThriveNYC’s first executive director. Less than a year later, de Blasio created the Office of ThriveNYC and put Herman, former deputy commissioner of collaborative policing at the New York City Police Department, in charge.

In March 2019, New York City Comptroller Scott Stringer, who is currently running for mayor, expressed concern over ThriveNYC’s lack of metrics and opaque finances. He sent a letter to Herman asking for better accounting of the program’s spending, which is spread across city agencies, and proof of its initiatives’ efficacy.

“We are having trouble looking at what Thrive is,” Stringer wrote. “One of the basic questions we are trying to figure out is, what is Thrive?”

Stringer noted that almost half of the 54 programs had disappeared from ThriveNYC’s most recent budget, and asked for an accounting of the number of people it had reached and helped.

At a City Council oversight hearing the next month, McCray distanced herself from the program’s day-to-day operations, saying her role is to take its “message to the public” rather than execute its goals. She deflected questions about ThriveNYC’s budget and outcomes to its incoming chair, Herman. In a letter, Herman told Stringer ThriveNYC was not “yet affecting a citywide metric on mental health” because it was too early in the program.

Under pressure, the Office of ThriveNYC released 472 metrics related to the success of its various programs, but few metrics on patient outcomes. Some initiatives struggled to attract and retain staff. The Mental Health Service Corps, for example, had only been able to fill 263 of the allocated 395 slots for clinicians to conduct outreach to needy communities.

Calls for reform became even louder after a string of violent incidents perpetrated by those with serious mental illness, including the bludgeoning death of four people in Chinatown by a man with 14 prior arrests in October 2019.

Under Herman’s leadership over the next year, ThriveNYC underwent a major overhaul. Herman streamlined the program’s six areas of focus to four – improving prevention and response, reaching youth, eliminating barriers to care and promoting mental health for those with serious illness – and cut its number of initiatives from 54 to 31. Working with CUNY’s Institute of State and Local Governance, she released nearly 100 metrics to measure the efficacy of ThriveNYC’s dozens of initiatives, publishing the data on the organization's website and pledging to update it regularly.

Thrive was in the midst of a reorganization when the pandemic hit. In April, the initiative dispensed with its name altogether, becoming the Mayor’s Office of Community Mental Health, a permanent organization at City Hall.

According to Belkin, the initiative’s expansive, innovative vision was winnowed down under political pressure to focus again on the most severely afflicted, rather than serving as a hub connecting efforts across city government and embedding mental health resources in the community. “When faced with criticism, instead of doubling down on Thrive’s vision and being more transparent and aggressive, the administration really ran away from the core part of the vision,” Belkin said.

Herman takes issue with this characterization. “Thrive, from the very beginning, has been about mental health for all New Yorkers. That is the ambitious vision that still informs our work,” she said. “To us, that has always meant that we reach people who might otherwise go without care – reaching everyone with need is what it means to serve all New Yorkers, in all neighborhoods, and at all levels of need.”

Among the key ThriveNYC programs that were jettisoned or scaled back was the beleaguered Mental Health Service Corps; the Maternal Collaborative, which focused on outreach to new mothers; and its collaboration with CUNY to measure its outcomes.

Along with Herman, Belkin bristles at the notion that ThriveNYC did not do enough to address serious mental illness. “A huge proportion of Thrive funding was specifically for what people often mean when they are talking about seriously mentally ill,” he said, citing Thrive’s 24-hour mobile crisis teams and investments in supportive housing.

Advocates for mental health say the city needs to dedicate more resources to addressing the issue in the wake of the pandemic. “A lot of people are experiencing anxiety or depression at levels never experienced before and seeking out mental health services in a way they haven’t before,” Shapiro said. “Community providers have been underfunded for a long time. There’s not enough of a workforce available and that really got exposed during the past year.”

Activists also want more money to replace hundreds of inpatient psychiatric beds that hospitals diverted to help address the needs of COVID-19 patients, increase services in schools for children who have been traumatized by the pandemic and expanded diversion programs to take responding to acute crises out of the hands of police.

Last year, the state government mandated that 30% of hospital beds be left vacant in case of surges in coronavirus cases. When the pandemic hit last spring, New York state appropriated around 400 hospital slots for COVID-19 needs, including 100 in New York City.

“Many hospitals disproportionately targeted detox and psychiatric beds to meet that mandate,” Shapiro said. “Even after the mandate is lifted, those beds aren’t coming back. Psychiatric and detox services are among the most costly for hospitals.” State regulators say they don’t expect any of those psychiatric beds to be permanently eliminated. Advocates counter that private hospitals were already reducing their in-patient psychiatric treatment capacity.

Absent a joint effort with New York state, the city is limited in its ability to reach those with the most serious forms of mental illness, said Giselle Routhier, policy director at the Coalition for the Homeless. “(ThriveNYC) has been able to chip away around the edges by providing a central phone resource for people to call, increasing its funding for street-medicine teams” and expanding the city’s “clubhouse services” – community centers where those with mental illness can access an array of resources, she said. “Those are all things that are helpful, but they don’t substitute for a broader fixing of the system, where we need adequate inpatient beds and outpatient services without having to jump through a bunch of bureaucratic hoops.”

Juvenile mental health advocates say schools need not just social workers who can refer students to outside services, but in-school professionals who can provide them directly.

“This is a really great time to do things differently and not operate how schools have been before the pandemic, where thousands of students a year in emotional crisis face NYPD law-enforcement interventions instead of mental or behavioral health professionals,” said Dawn Yuster, director of the School Justice Project at Advocates for Children of New York. “We need not just more social workers, but behavioral specialists who are clinically trained.”

The ultimate fate of ThriveNYC and the city’s mental health infrastructure lies in the hands of the next mayor. De Blasio is term-limited and the Republican candidates running to replace him have demanded an investigation into the program’s spending and efficacy. Democratic candidates have praised the intentions behind ThriveNYC, but criticized their execution. While some plan to keep or expand some of its initiatives, the “ThriveNYC” branding will likely be retired.

Andrew Yang, one of the top contenders in the mayoral race, proposes to increase the number of social workers and mental health professionals in schools, create rapid-response services for crises currently handled by police and expand psychiatric care support for COVID-19 long-haulers and medical providers who have been traumatized by the pandemic.

Brooklyn Borough President Eric Adams’ plan, on the other hand, pledges to focus on those with serious mental illness, including building 15,000 supportive housing units over the next 10 years. “Our primary focus must be on supporting individuals with severe mental health challenges,” Adams said in a statement. “My administration will increase the number of inpatient psychiatric beds.” Adams also promised to invest in “crisis stabilization centers” for those whose acute crises do not require a hospital stay.

Stringer and nonprofit executive Dianne Morales plan to do away with the concept of ThriveNYC entirely. "Mental health must be at the center of our COVID-19 recovery, and as mayor, I'll make that happen by replacing ThriveNYC with a true, world-class mental health care system,” Stringer told City & State.

Morales, who like Stringer has pledged to keep ThriveNYC’s NYC Well hotline but move it into the Department of Social Services, said the fallout from the pandemic showed that ThriveNYC failed to address the root causes of mental illness, which she identified as poverty, homelessness, employment insecurity and policing.

“In the middle of the pandemic, we had an increase in homelessness and safety issues,” she said in an interview. “All these things were linked. We need to acknowledge the complex and comprehensive solutions to address these issues. For too long, we’ve taken a siloed approach to addressing mental health.”

Like Yang, former Sanitation Commissioner Kathryn Garcia’s plan includes addressing the impact of the pandemic on school children and intervening in mental health crises – whether in schools or on the streets – before police involvement is required. She plans to expand the number of psychiatric beds available in New York City and promote telehealth to improve access. The Garcia campaign has said it would invest in existing mobile-crisis teams and ensure mental health professionals respond to 911 crises alongside police.

Noting that ThriveNYC was a “good idea badly implemented,” former de Blasio administration counsel Maya Wiley pledged to keep some of its programs while doing away with the name.

“We don’t want to scrap what works as punishment for a new label that got tarnished by the current administration’s branding,” she said. “It is not enough to have good ideas. They must be effectively implemented. That requires innovation and partnerships inside and outside of government and transparency and accountability so we celebrate what works and fix what doesn’t.”

Herman, ThriveNYC’s former director and now head of the Mayor’s Office of Community Mental Health, said the idea behind ThriveNYC was “not to try to replicate or create an alternative mental health care system, but to fill gaps in the system.” The organization, she noted, has made many of the investments critics and the mayoral candidates want. She defended the program from those who say it either focuses too little on those with serious mental illness or has abandoned its broad scope in the face of political pressure.

“Both in response to feedback and in response to our desire to do more in many areas, we have done significant work for people with serious mental illness,” Herman said.

In addition to expanding mental health mobile crisis teams, in February ThriveNYC launched a pilot program in Harlem and East Harlem that dispatches psychiatric care workers and EMTs, rather than police, to mental health crises. Herman noted that ThriveNYC has added to the city’s Health Engagement Assessment Teams, which follow up with those with frequent 911 contact, and invested in the existing clubhouse system. 

“It’s very important to serve people and think about the entire lifespan, from birth to old age, and to think about prevention as well as crisis response,” Herman said. “The Mayor's Office of Community Mental Health promotes mental health for all New Yorkers – in every community, at every level of need, and at every stage of life. It's not a question of either/or – we need all of the above.”

Whatever the next mayor makes of the Mayor’s Office of Community Mental Health, the work of expanding the city’s services to meet all New Yorkers’ needs has only just begun. McCray, however, has abandoned talk of any run for political office.

Correction: Subway assault statistics do not specify whether the perpetrators were mentally ill.