Opinion: Public policy insanity

It’s often said that the definition of insanity is doing the same thing over and over again and expecting a different result each time.

By that definition, New York City and New York state’s approaches to solving our systemic mental health and related homeless crises have been insane for more than four decades.

I’m old enough to recall the fascinating and vexing case of Joyce Brown (aka “Billie Boggs”), a homeless, mentally ill woman who lived and slept on an air vent on 65th Street and Second Avenue near a Swensen’s ice cream shop. In 1987, she became the first person hospitalized under a controversial program by New York City Mayor Ed Koch that expanded the city’s ability to forcibly admit homeless New Yorkers to psychiatric hospitals like Bellevue on the East Side of Manhattan.

During her trial, Brown took the stand and astonished the public with her clarity in defending her right to sleep on the street. Following her release from Bellevue, she made numerous television appearances and even spoke at Harvard Law School about the legality of homelessness. Her case sparked a national conversation about the best way for cities to approach people with mental illness who rejected care and insisted on living in public spaces.

That was almost four decades ago. Since then, New York has had a plethora of other fascinating and widely covered cases and attempts at legal solutions: “The Wild Man of West 96th Street” in the early 1990s, Kendra’s Law in 1999 and most recently New York City Mayor Eric Adams’ crackdown on removing homeless mentally ill people from our streets and subways.

And still, this issue festers and persists in our public policy debates. Now Gov. Kathy Hochul is under pressure to expand the criteria for forcibly removing homeless mentally ill people from public spaces. A recent study showed 88% of New Yorkers support more stringent guidelines on this chronic and persistent social ill.

But forcible removal, debates about civil liberties and a “get tough” approach will not solve this systemic problem. There are a number of structural and long-term investments that must be made in our public health infrastructure in order to solve this age-old and seemingly intractable problem that breaks the hearts of compassionate New Yorkers on a daily basis.

Severe mental illness is just that – an illness – that should be treated with the same compassion and care as cancer or heart disease.

If someone is diagnosed with breast cancer, we don’t jolt them out of bed, drag them to an ill-equipped hospital, expose them to substandard conditions and then send them to fend for themselves after they’ve had a chemo treatment.

We give these victims of disease compassionate care, expert medical advice, a few-day hospital stay in a comfortable bed in a clean room and then frequent after care visits to ensure their recovery from the disease.

Why should severe mental illness be treated any differently?

Society stigmatizes those with schizophrenia and other serious mental illnesses. We don’t want to see them on our streets or in our subway cars, exhibiting dramatic outward symptoms of their illness. It jolts us, scares us, makes us feel uncomfortable. But in most cases, these distressed human beings are harmless and simply need a humane alternative to the streets and dangerous homeless shelters.

There are a variety of long-term fixes that our elected leaders must find the resources and will to implement. Otherwise, we will be having the same debate in four decades, just as we are now, long after Joyce Brown so articulately and painfully brought this into public view.

Here are some ideas that Hochul, Adams and members of the state Legislature and New York City Council need to consider and act upon with urgency.

Build or retrofit facilities with thousands of short- and long-term psychiatric beds

The deinstitutionalization movement of the 1960s and 1970s was a well-meaning but disastrous public policy blunder. The hope was that small community-based facilities would fill in the gaps for these large institutions. But NIMBYism, callous disregard for the suffering of our neighbors and governmental inaction led us down this calamitous path.

In New York state, we had 10,200 psychiatric beds in 2014. By 2022, that number had declined to just 9,100 beds. Not coincidentally, it is estimated that we have more than 1,000 severely mentally ill people in our prisons. Rikers Island has by default – and with no appropriate care or resources – become the largest psychiatric facility in the state. This is clearly the wrong public policy and must be addressed immediately. Even 10,200 psychiatric beds aren’t enough for a state with nearly 20 million residents.

The state must figure out how to increase the number of psychiatric beds to at least 12,000-15,000 by 2027, while at the same time upgrading facilities so they become viable options for seriously mentally ill people on our streets and subways.

This is clearly achievable through budgeting, priorities and execution. With all the underutilized commercial space in New York City, plus shuttered prisons and other large facilities, the built space exists to accelerate this process.

Build tens of thousands of new supportive housing units

Right now, New York City has only 32,000 supportive housing units, and the state as a whole has just 50,000 units.

By one estimate, there are more than 250,000 people in New York City who suffer from severe mental illness, and more than 40% of people with severe mental illness go untreated. As of July 2024, there were 132,000 people sleeping in New York’s temporary shelters and at least 4,000 more living on the streets and in the subways.

Clearly, the math on supportive housing is not adding up. With so many office buildings in New York looking to convert from office to residential, why can’t the city (and the state) begin to allocate proper resources to creating many more supportive housing units?

We hear constantly about ambitious plans to build affordable housing, a laudable goal. But lost in the discussion is the need to build housing that includes drug and alcohol treatment facilities as well as other rehabilitative mental health infrastructure to offer a true “housing first” policy to help New Yorkers who are mentally ill and homeless.

Create dozens more crisis respite centers in New York City

Respite centers serve as alternatives to hospitalization for those experiencing a mental health crisis. These centers provide onsite mental health care for up to four weeks. People who check themself into these centers are called “guests” and can go about their daily activities while receiving mental health care and referrals to medical and psychiatric providers.

Right now, there are only 11 respite centers in the city. The Bronx, home to more than 1.4 million people, has just one respite center. There are only two in Queens for a borough of more than 2.3 million. There’s only one on Staten Island for almost 500,000 residents. You get the idea.

Fund a large expansion of clubhouses for severely mentally ill people

Every elected leader around New York state should tour Fountain House on West 47th Street, like I did two months ago. It is a marvel of a nonprofit that works perfectly to serve its “members” – more than 1,300 seriously mentally ill people across the city. (For full transparency, my youngest daughter works as a policy analyst at Fountain House).

There are too few clubhouses in the city to meet the demands of a growing population of those with severe mental illness. Clubhouses are premised on the beliefs that community is a therapeutic intervention and relationships developed through working together help to improve self-esteem and decrease isolation and loneliness. This kind of holistic care model seeks to address the social symptoms of serious mental illness and help members on their path to recovery.

The Fountain House clubhouses are divided into units of interest, such as the “Home and Garden Unit,” the “Wellness Unit,” “The Communications Unit,” and “The Culinary Unit.” Members at Fountain House work alongside staff within these units, building a sense of inclusion and agency.

Let’s face it: Housing and supportive services are just a few pieces of the puzzle to fix the chronic crisis of homelessness and mental illness. Giving people with serious mental illness a place to go each day and learn work skills while building community is vital to their recovery and path back to living a healthy and productive life. Our government needs to fund dozens more clubhouses like Fountain House around the state.

Arvind Sooknanan, a member of Fountain House’s board of directors, wrote earlier this year for City & State about the value of mental health clubhouses. He’s also a senior adviser to Assembly Member Jenifer Rajkumar, who just introduced an ambitious bill called the Empire State of Mind Act, which would provide wraparound services – including housing, employment support and clubhouses – to anyone discharged from a hospital after experiencing a mental health crisis.

Whenever there is a high-profile incident on the subway or on the street, everyone defaults to the lazy solution of “involuntary commitment,” which has been a failed policy for more than four decades. Meanwhile, we are woefully underfunding potential solutions to serious mental illness and homelessness.

Instead of continuing the charade that a failed mental health system will be fixed by forcing people into it against their will, isn’t it time for Albany and City Hall to start talking seriously about funding first resort programs that can permanently alleviate this chronic problem?