Chirlane McCray on Rikers Island (photo: Michael Appleton/Mayor's Office)

A rising number of 911 calls to report emotionally disturbed persons, several fatal encounters between police officers and people with serious mental illness, and an increasing percentage of seriously mentally ill people among those detained in city jails have all raised questions about how New York City and State provide care for those suffering from the most serious mental illnesses.

These questions and concerns don’t have easy answers. The city’s public hospital system, NYC Health + Hospitals; the mayor’s mental health care roadmap, ThriveNYC; services from the city’s Department of Health and Mental Hygiene; treatment within the city Department of Correction; private clinics; mental health shelters; and more combine to create a complex and stratified framework for treating those with a serious mental illness (SMI).

For some, much of what is at times called a crisis of treatment for those with serious mental illnesses like schizophrenia can be traced to the trend whereby the state closed down psychiatric hospitals with many thousands of inpatient beds while requisite treatment systems were not put into place to help people who would no longer be institutionalized, many of them cycling through the criminal justice system and inappropriately receiving their best mental health care while in jail.

There is insufficient use of mandatory outpatient treatment, some critics of the city and state say, with significant recent criticism also aimed at Mayor Bill de Blasio and First Lady Chirlane McCray over how resources have been allocated in their signature ThriveNYC program. Meanwhile, others have focused on questioning that police officers with guns are often first responders to people experiencing a serious mental health crisis, and those critics have been successful to some extent in getting protocols changed, though they say there is clearly more to do.

Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, says he’s troubled by the gaps in treatment and looking for new answers that would require the city and state to work together.

“The problem with the current mental health system, from my point of view, is for people with serious mental illness, the people we most worry about, the people we sometimes see on the subway or sitting on the bench, that right now there is nothing in between acute hospitalization and traditional outpatient care,” he said in April during an appearance hosted by the Citizens Budget Commission (CBC), a nonprofit think tank.

During an interview after the CBC event on the What’s The [Data] Point? podcast from CBC and Gotham Gazette, Katz was asked for more on his view about how to fill that gap.

He said H+H is working with the state on fixing a system that “drops off too precipitously.” Katz said he was in discussions to create programming to increase services for those who don’t qualify or don’t want to be admitted for inpatient care at a hospital but don’t receive enough treatment or care in the current outpatient system.

“We know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail,” he said on the podcast. “They don’t need to be locked up but let’s provide them a positive residential program that they want to stay at because it’s better than shelter and it’s better than the jail when we know that there are people who get arrested in order to be taken care of in jail.”

Over the course of months since Katz’s April comments, Gotham Gazette reached out multiple times to New York City Health + Hospitals and the Mayor’s Office but didn’t receive any further details on Katz’s vision for the program or whether there are ongoing discussions to make it a reality. State law and the state Office of Mental Health (OMH) have near full authority over the types of mental health treatment options allowed throughout the state, and are essential to the discussion, as Katz indicated.

In a statement to Gotham Gazette, a spokesperson for the New York State Office of Mental Health said, “as New York State continues to transform its mental health system to serve more individuals in the least-restrictive setting possible, we are expanding our reach through community-based services. These treatment models allow people to stay in the communities where they are best supported.”

Serious mental illnesses are not the types of mental illnesses and mental health issues that plague a little under 50 million Americans; according to the National Institute of Mental Health, about 4.5% of American adults have a serious mental illness -- meaning roughly 239,000 New Yorkers based on population statistics.

The three most common SMIs are schizophrenia, bipolar disorder, and major depression – less severe depression and anxiety are not categorized as serious mental illnesses although both the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) agree there is some ambiguity in the cut-off line for what’s considered a “serious” mental illness. It’s also important to note that there are complications with the term “serious mental illness”; it is not a diagnosis itself, but a level of disability or a threshold for having a particularly significant and debilitating mental illness.

In asking how New York treats those estimated 239,000 New Yorkers, there are the unavoidable questions of where they can and should be treated, as Katz indicated. Back in the early 20th century, many people with SMIs were admitted into state psychiatric centers, more commonly known as “insane asylums”; however, over the past 80 years there has been a major shift in placing those with serious mentally illness into inpatient treatment.

In the 1950s, New York began deinstitutionalization – a shift from inpatient care (a patient admitted into a hospital full-time) to community-based outpatient care. According to a 2018 report by Manhattan Institute senior fellow Stephen Eide, the process of deinstitutionalization continues to this day but may have gone too far. According to the report, the city’s public hospital and health care system, NYC Health + Hospitals, is the leading provider of inpatient psychiatric care in the city with only 1,218 beds dedicated to adult inpatient psychiatric care, representing 48% of adult inpatient beds in the city. State psychiatric centers in the city account for 1,058 adult inpatient beds.

ThriveNYC, led by McCray, has come under fire on multiple fronts, including general money mismanagement and lack of clear outcome-tracking, but also for how it helps -- or doesn’t help -- those with serious mental illnesses. During a City Council budget and oversight hearing on March 26, McCray was pressed on the issue several times, including pointed questions about how much of the ThriveNYC budget is dedicated toward treatment for those with SMIs.

At one point she said, “All of Thrive is really focused on the seriously mentally ill,” but she and others who testified about the program eventually offered more clarity.

Thrive, which is called a “roadmap” and spends around $200 million per year on programming and coordination, does include services solely focused on those with serious mental illness, but its main objective is to plug gaps of already existing services run by H+H and the city Department of Health and Mental Hygiene (DOHMH), while reorienting health care to always include mental health care and extend awareness and treatment into all of the city’s communities.

“Thrive is dedicated to prevention when possible, early prevention, treating people in crisis, and making sure people are stabilized when they do reach a crisis point,” McCray said. In arguing that all of Thrive is aimed at serious mental illness, she argued that untreated lower-level mental health issues can spiral.

Thrive, in the context of treating those with SMIs, is criticized for focusing more on mental health rather than mental illness; most of its 54 initiatives are focused on combating stigma, the negative factors that can lead to mental illness, and encouraging people to spot mental health issues in others and themselves, and to seek help.

In a May op-ed in the New York Post, DJ Jaffe, the executive director of Mental Illness Policy Org, and Eide of the Manhattan Institute called for the reallocation of ThriveNYC’s entire budget to focus on those with serious mental illness. They offered specific ways in which to redirect funding into different programs, such as enhancing existing crisis intervention teams, creating an office to exclusively manage the use of Kendra’s Law in New York CIty, and promoting supportive housing for homeless people with serious mental illnesses.

“The most serious cases are the ones most likely to become homeless, arrested, incarcerated, hospitalized and violent if they go untreated,” they wrote. “Yet Thrive virtually ignores this group in favor of people with less severe illnesses.”

Susan Herman, the recently-appointed executive director of ThriveNYC, said during the March testimony, “we are filling strategic gaps and piloting innovative programs for the seriously mentally ill to be able to work with people so they can stay in community by connecting them to services, by helping them connect or reconnect to treatment. We’re helping people both before crisis and after crisis.”

For example, McCray said in an op-ed in New York Daily News that Thrive adds $30 million of funding (about 15% of its budget) to the $300 million the Department of Health and Mental Hygiene already spends directly to help people with SMIs.

“Thrive-supported programs are designed to enhance and complement these existing services, not compete with or replace them,” she wrote.

For someone who voluntarily requests care, they can go to a public hospital for informal short-term hospital care as well as traditional outpatient care. The average stay for someone hospitalized for mental illness is 11 days, according to the New York City Department of Health and Mental Hygiene.

Outpatient care -- preferred by many for its community-based nature -- consists of things like meeting with a therapist or a psychiatrist and getting medication prescribed. Influential 1999 Supreme Court case Olmstead v. L.C. ruled public entities must provide community-based services to those with mental illness whenever possible.

“Lots of people have schizophrenia,” says Dr. Gary Belkin, Executive Deputy Commissioner for Health and Mental Hygiene in the city's Health Department and Chief of Policy and Strategy of ThriveNYC, in a phone interview. “The vast majority don’t end up on the street untreated and that’s because there are things that happen earlier, things that Thrive is working on – getting better care connections, having many points of contact, opportunities for family/friends to bring them mobile help."

Thrive has Assertive Community Treatment (ACT) teams dispatched around the city, often in mental health shelters, to treat people with serious mental illness. There are at least 50 ACT teams in New York with the capacity to serve 3,500 people at any time, according to Herman’s March 26 testimony. Thrive also created intensive mobile treatment teams that mostly go to shelters and provide treatment for homeless people. These outreach efforts mostly help people with outpatient care, but can lead to more intensive intervention, though it is very rare for judges to order people into inpatient hospitalization in New York.

Some of these efforts will now be part of ThriveNYC’s recently-announced outcome-tracking procedures, announced in late June.

The key questions, it seems, are whether Thrive’s efforts and the increased emphasis on outpatient programs on the state level -- perhaps including what Katz of H+H said he’d like to see -- can successfully fill gaps left by deinstitutionalization, while creating a more humane care system, and reduce threats posed by those with serious mental illness to themselves and others.

Deinstitutionalization in New York has been drastic. According to Eide’s report, as of November 2018, the average daily number of people in New York state adult psychiatric centers was 2,267. In 1955, there were over 93,000. Even in just the last four years, the number of state inpatient psychiatric beds -- in other words, the capacity for inpatient care -- has dropped by 19% statewide, from 2,866 in 2014 to 2,335 in 2018.

The drop in average daily patients and inpatient beds has coincided with an increase in the number of seriously mentally ill homeless people in New York and the proportion of inmates with a serious mental illness diagnosis in city jails.

According to Eide’s findings, there are more psychiatric beds in New York City mental health shelters than the number of psychiatric beds in state psychiatric centers and Health + Hospitals facilities combined.

Supportive housing, which provides housing and social services for those with serious mental illness, is also seen as a key tool. There are currently 52,000 units of supportive housing statewide, half of which are funded by the state Office of Mental Health (the other half don’t necessarily serve those with mental illness). Supportive housing, which is built and funded by both the city and state, sometimes in conjunction, is typically run by nonprofit providers who provide onsite mental health care, medication delivery systems, and more.

According to testimony given in a May City Council hearing by the Supportive Housing Network of New York, there are around 33,000 units of supportive housing in New York City. Amid calls for more units, both Mayor de Blasio and Governor Andrew Cuomo have made pledges to develop more supportive housing.

In his NYC 15/15 Supportive Housing Initiative announced in November 2015, de Blasio said the city would develop 15,000 additional units of supportive housing over 15 years. Two months later, Governor Cuomo announced his plan to build 20,000 units over the same 15-year timespan. These announcements came after the two were unable to come to an agreement on what have been known for decades as “New York-New York” supportive housing deals whereby the city and state work together to develop thousands of units.

The New York State Senate and Assembly Democratic majorities see a need for more programming aimed at mental health care and housing, too. Earlier this year, the two bodies unanimously passed a bill creating a temporary commission to study what is seen as chronic underfunding for these housing programs. The commission would “provide policy guidance and recommendations relating to the adequacy of funding levels and need for sufficient staffing in all supportive housing under the auspices of the Office of Mental Health.”

According to a June 25 press release from supportive housing provider Bring It Home, “[t]he bill would prompt a study of current funding and staffing levels across the state and investigate ways the state can begin to remedy its years-long failure to adequately fund mental health housing programs.” Advocates are urging Cuomo to sign the bill so the commission can issue its report in time for the next state budget season.

Another discussion that has played out over many years, at the state level especially, is over how to treat individuals who are too sick to seek help.

Per New York State Law, the criteria to involuntarily admit someone due to mental health is fairly strict – the person can’t understand the need for care or presents a substantial harm to self and/or others, among other standards.

According to a 2015 New York City Department of Health and Mental Hygiene report, 40% of adult New Yorkers with serious mental illness didn’t receive medical treatment in the prior year.

Courts can and do order people to outpatient care: assisted outpatient treatment (AOT) is also known in New York as Kendra’s Law. Originally passed in 1999 in New York State (the first law of its kind and emulated in many other states since), Kendra’s Law allows select people close to a mentally ill person to petition the court to mandate a treatment plan for that person. According to OMH’s website, as of Monday (July 29) there were 3,109 people under active court order via Kendra’s Law, 1,377 of them in New York City.

Jaffe of Mental Health Policy Org, a staunch supporter of Kendra’s Law, estimates around 4,000 people should be in mandated treatment under the law. Critics of Kendra’s Law typically accept the principle but say it’s overly strict, such as the need to show an instance of seriously violent behavior in the last four years. Once a petition to mandate care is successfully filed, the chances of the courts granting the petition are extremely high: 90% of Kendra’s Law petitions were granted statewide from July 29, 2018 through Sunday (July 28, 2019), according to OMH’s website.

Kendra’s Law affects a very small population but has shown signs of working: the state Office of Mental Health says for someone who went through an assisted outpatient treatment program, psychiatric hospitalization was reduced by 64% after AOT, incarceration by 72%, and homelessness was reduced by 61%. Jaffe and Eide in their op-ed call for the creation (and funding) of a Kendra’s Law Office to deal solely with helping the city expand its efforts to get more people into Kendra’s Law.

Meanwhile, ThriveNYC offers NYC Well, a mental health helpline that has the ability to dispatch mobile crisis intervention teams to someone experiencing a mental health crisis. The phone line is something that de Blasio and McCray often cite in their public remarks about Thrive and the city’s efforts to improve mental health care.

Another big piece of the current picture of care for those with serious mental illnesses is correctional health services, which have been needed more and more. Although the daily inmate and detainee population in city jails is decreasing, the percentage of those diagnosed with a serious mental illness has gone from 10.2% in city fiscal year 2014 to 14.3% in fiscal year 2018, according to the Mayor’s Management Report.

Dr. Katz  said on What’s the [DATA] Point? that “In the case of correctional health…we know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail.”

One goal of ThriveNYC is to limit the number of people going to jail due to serious mental illness. The city will open two health diversion centers later this year. Announced in late 2018, the diversion centers will provide somewhere for police officers to take someone who has committed a low-level, non-violent crime but they believe is exhibiting behavioral problems due to mental health. The centers will offer mental health treatment and have overnight beds but stays will be capped at five days.

Skeptics of the idea point out that there will only be two diversion centers, one in the Bronx and one in East Harlem, and each center will only serve its specific community. Plus, the centers will have a “no-refusal” policy that could edge out those with serious mental illness if the centers are at capacity. According to Herman at the March City Council hearing, Thrive plans to evaluate the success of the two programs and possibly create more centers next year.

“We want to catch [people] before entry into the criminal justice system,” said Dr. Belkin. “Nobody should enter the criminal justice system for something related to mental illness. We should be able to reach those people so that doesn’t happen, where they can be treated and managed in a health context before they get ensnared in the criminal justice system. I think everyone wants to avoid that path."

Critics argue, as alluded to by Katz and recently brought up during a Council hearing on recidivism of those with mental illness, that mental health services outside of the criminal justice system are less robust than those offered in city jails. According to Katz, “the fact that we make it necessary for some people to commit shoplifting in order to ensure they’re in a safe place, get their meds, get their food, get their house, when we could do that so much less expensively elsewhere is really a condemnation on us.”

Another option, proposed by Jaffe and Eide, is the expansion of mental health courts, which allows judges to divert those with serious mental illness and charged with crimes to treatment instead of jail. They say current mental health courts cannot offer housing to these people, which weakens its effectiveness.

City Council Speaker Corey Johnson is attempting to prevent those with mental illness from going to jail and to ensure they get better treatment instead. In a speech on criminal justice reform on May 16 at John Jay College, he announced the Council will create a program to house 100 people with SMI caught in the criminal justice system and emphasized the 100 beds are a start, but the program will need further investment and focus to add more beds.

Johnson also pointed out how targeting the legal system can keep people with SMI out of jail; he announced the Council will fund a program to connect social workers with defense attorneys to find alternatives to prison. He also previewed the Get Well & Get Out Act, which would require correctional services staff to keep attorneys informed of their clients’ mental health.

The bill was introduced on June 13 by Council Member Margaret Chin of Manhattan and six other Council sponsors, including Speaker Johnson. The Council quickly held a hearing on the bill that was combined with an oversight hearing on recidivism rates for those with mental illness. The bill has not yet received a committee vote.

How the city handles crisis situations including people with serious mental illness has come under increased scrutiny over the last few years. According to the NYPD and an investigation from THE CITY, calls to 911 involving EDP’s, or emotionally disturbed persons, have risen from around 97,000 in 2009 to 180,000 last year. Fourteen people who appeared to be suffering from acute mental illness have been killed by police officers in the past three years.

The extent to which the city’s roughly 37,000-member police force has been trained in crisis prevention is an ongoing issue. THE CITY estimated that only about 11,970 uniformed officers had undergone crisis prevention training at the time of its March reporting.

In April 2018, de Blasio and McCray launched the NYC Crisis Prevention and Response Task Force to create a strategy to better deal with mental health crises in the city. That report was due in January and has not been publicly released. The Task Force consists of leaders from the Department of Health and Mental Hygiene, ThriveNYC, and the NYPD, among others.

McCray in her Daily News op-ed said serious mental illness and EDP calls aren’t as related as they appear.

“Unfortunately, too many people think of serious mental illness as ‘crazy people in the subway,’ or 911 calls involving emotionally disturbed persons. But not everyone sleeping in the subway or on the streets has an illness,” she wrote. “And emotional disturbance describes erratic behavior at a given time — not a chronic disease.”

In an attempt to treat EDPs, Thrive created what it calls co-response teams that proactively send a police officer with a clinician to people who have shown violent tendencies or behavioral problems in the past. The forensic ACT teams, the mobile intervention teams, and the co-response teams are all a part of Thrive’s NYC Safe program.

It’s possible that the program Dr. Katz spoke about in April -- creating a residential program for the seriously mentally ill to fill in the gaps of treatment between outpatient care, inpatient care, and prison -- is what’s called “Intensive Outpatient Treatment,” or IOT, which offers a much higher intensity of services but still in the patient’s community. Patients under IOT would visit a psychiatrist more often and for longer than traditional outpatient programs.

Already existing outpatient programs must apply for a waiver to the state Office of Mental Health for permission to offer an intensive outpatient treatment program. OMH has approved waivers for 35 clinics beginning in August 2017, according to OMH’s website (they are required by state law to publicly release waiver requests and decisions).

Otherwise, the most intensive treatment with the most consistent care can be found in hospitals, prisons, or homeless shelters.