Solving New York’s mental health crisis

The next mayor of New York City will have to confront a long menu of challenges, but there is one at the nexus of many of these: the mental health crisis playing out daily on the streets and in our subways.

This is not a “let’s clean up our streets and subway” moment, it’s a “let’s give people community, opportunity, dignity and support” challenge.

Now that the city is opening up, it has a historic opportunity to ensure that one the most vulnerable groups is not left behind – those living with serious mental illnesses, which is a mental health issue which substantially interferes with major life activities, such as schizophrenia or bipolar disorder.The de Blasio administration has taken a first step in making community mental health a priority through its ThriveNYC initiative, now morphed into the Mayor’s Office of Community Mental Health, but much more work needs to be done to improve the current system.

While this investment – that the biggest city in the United States made mental health a priority – is a step in the right direction, it is a mere drop in the bucket of resources needed to address the 280,000 people living with serious mental illness in the city. Even among those with health insurance, just over 50% are not receiving any care.

If half of the population in Manhattan with severe heart disease or cancer were not receiving treatment, public concern and government efforts to expand care would be a given. And yet the state of our public conversation about serious mental illness, especially in the current mayoral race, is to conflate it with violence and risk to the public and to focus almost entirely on whether the police or mental health professionals respond to 911 calls. In fact, people living with serious mental illness are far more likely to be the victims of violence than to perpetrate it.

While reform of police response to mental health crises is essential, it is just the front end of a much wider mental health and public health system that is failing too many New Yorkers. To rebuild public health, the next mayor must make community-based solutions for people with serious mental illness a top priority and standard practice – something that should have happened in the more than five decades since the deinstitutionalization of thousands of patients from psychiatric hospitals around the state.

We are in no way suggesting going back to large, inhumane and ineffective facilities of the 19th and early 20th centuries. The 21st-century solution to serious mental illness is providing care, supportive services and housing in small, community-based programs that have a track record of durable engagement of people with serious mental illness and better health outcomes. We need basic social infrastructure for these New Yorkers.

When the next mayor takes the oath of office on January 1, 2022, one of their first priorities must be solving this chronic crisis. The next administration needs a three-pronged approach to this: housing, health care and community.

On the housing front, we need to work with the state Office of Mental Health to roll out a massive expansion of behavioral health supportive housing, including streamlining access to existing beds through these programs. Every night, there are empty behavioral health supportive housing units in New York City because of the byzantine and unrealistic enrollment and eligibility criteria. We also need to reclaim unused hotels for supportive housing, akin to California’s $850 million hotel reclamation plan for the homeless.

To improve health care, we must expand the pool of behavioral healthcare workers through incentive programs, such as student loan forgiveness, to practice in low-income communities and integrate behavioral health services into primary care – essentially a better-designed and better-executed version of ThriveNYC’s Mental Health Service Corps, which has been consistently underfunded and has a history of disorganization.

Additionally, the city must work with the state to better enforce mental health parity laws (which ensure that health insurance plans cover behavioral health and physical health benefits equally, but regulators must work harder to get insurers to comply), expand access to telehealth and mental telehealth services, and make permanent the equalization of insurance reimbursement for telehealth and in-person services. It also must focus workforce deployment in mental health deserts like the South Bronx, Central Brooklyn, the Rockaways, and other underserved areas.

The final piece of the roadmap is increasing access to community care. The next mayor needs to make an annual $1.5 billion investment, which is what it would cost to place the whole population with severe mental illness in community-based mental health programs such as Fountain House, which serve as therapeutic communities, and provide the basic social infrastructure needed to support and durably engage people living with serious mental illness. We need to move people away from punitive, carceral systems and into programs that break debilitating social and economic isolation, and meet their basic needs for housing, education and employment, while providing easy and low-cost access to health care.

This seemingly large investment will pay dividends for years and save the city money in the medium-term. We know this approach works because one of us runs Fountain House, which has been doing precisely these things for the last 73 years here in New York.

Compare these facts: it costs $48,000 to house one person in the shelter system annually and approximately $340,000 annually to incarcerate one person. New York state spends half a billion dollars a year on incarcerating people with serious mental illness. But it only costs about $26,000 per year for Fountain House to provide a member with access to its employment, education, and wellness services and peer community, while also providing safe, supported housing.

Studiesshow that incarceration, even for those merely awaiting trial, can exacerbate or even cause mental health issues. Rikers Island has become one of the largest psychiatric facilities in the nation: it is estimated that40% of those incarcerated there suffer from a significant mental health issue.

The results at Fountain House speak for itself: nearly 40% of its members are or have recently been homeless when they arrive – within one year, 99% are in stable housing; 25% of Fountain House members are currently or were recently involved in the criminal legal system – while only 5% recidivate; and health care costs and hospitalizations for Fountain House members are down by more than 20% compared to non-members with similar conditions. Fountain House and its model clubhouses work and have been right under our noses for decades. As a start, Fountain House recently leveraged a historic $4 million from the city for New York City-based clubhouses, communities run by people affected by mental illness, in collaboration with professional staff, that focus on the strengths of the individual and what they can contribute, rather than their illness. That’s a 50% increase in the overall clubhouse budget for the city – but more resources are needed.

There are many other good examples of programs in the city that tackle aspects of getting the homeless or recently incarcerated employment and housing, including the Fortune Society and the Doe Fund among them. We need to focus on building strong partnerships with these programs to ensure we are tackling these issues from every angle, as embodied by the recent Fountain House-Fortune Society OnRamps partnership, funded by the Mayor’s Office of Criminal Justice, to house and support people with serious mental illness granted early release from Rikers during COVID-19. This kind of collaboration must be standard practice.

Instead of punitive jail sentences, ineffective crisis response and undignified and dangerous housing in shelters, the city should move that money into a mental health fund of $1.5 billion to pay for these programs.