The Elephant in the Room
On Tuesday, November 29th, Mayor Adams announced a controversial new plan to forcefully hospitalize New York City’s most vulnerable: the unhoused population.
"For too long, there has been a gray area where policy, law, and accountability have not been clear, and this has allowed people in need to slip through the cracks," Adams said.
Mayor Adams’ directive states that outreach workers, city-operated hospitals, and first responders have the legal authority to provide care to New Yorkers when severe mental illness prevents them from meeting their own basic needs.
The directive seeks to dispel the “myth” that the legal standard for involuntary intervention requires an “overt act” demonstrating that the person is violent, suicidal, or engaging in outrageously dangerous behavior likely to result in imminent harm.
Adam’s plan has received harsh criticism due to the lack of training for first responders, specifically the police, with many drawing illusions to this being another overreaching policy like stop and frisk. And pointing out the many challenges in implementing this plan, like the fact that the number of respite care centers, which the city uses to house those experiencing a mental health crisis, have been cut in half over the past three years, according to a recent report from the Office of the Public Advocate Jumaane D. Williams.
As of September of this year, there are more than 60,000 homeless people, including 19,310 homeless children, sleeping in New York City's main municipal shelter system, according to the Coalition for the Homeless. This does not account for the countless others who do not report to shelters, the voiceless. We do not know their names, their stories, or their circumstances. But what we do know is that they deserve basic human rights.
“We are defaulting to an extreme that takes away basic human rights,” Matt Kudish, CEO of the New York chapter of the National Alliance on Mental Illness, said in a statement after Adams’ announcement.
Kudish said New York should do more to help people before they need intervention: “The City has the power to provide onsite treatment, as well as treatment in homeless shelters or supported housing, but has chosen not to.”
As a peer advocate for NAMI who serves as a co-chair on the co-occurring illnesses subcommittee, Mayor Adams, I am sure you have carefully considered how to delicately address the unhoused situation and address the mental health crisis our city is facing. But what you have failed to address, is the staggering amount of co-occurring disorders the unhoused face, which is an added layer to this crisis.
According to a 2013 report by the New York State Health Foundation, in New York State alone, an estimated 1.4 million people —7% of the state’s population—suffer from a co-occurring disorder, and only 10% of those diagnosed receive treatment for both conditions. When left untreated, people with co-occurring disorders are at a higher risk for homelessness, suicide, incarceration, and early death.
According to SAMHSA, co-occurring disorders may include any combination of two or more substance use disorders and mental health disorders identified in the Diagnostic and Statistical Manual of Mental Disorders. No specific combinations of mental health and substance use disorders are defined uniquely as co-occurring disorders.
By only treating the mental health component of the unhoused, we are putting those living with a co-occurring disorder and with substance use at risk. Because if you prescribe someone who has a co-occurring disorder, and the prescribing clinician is not aware of the patient’s history with substances, they are more likely to misuse their prescribed medications, or can misuse substances as a way to self-medicate for their mental health problems.
Mental and substance use disorders also share some of the same underlying causes, including chances in brain composition, genetic vulnerabilities, and early exposure to stress or trauma.
Certain illicit substances can cause people with a substance use disorder to experience one or more symptoms of a mental illness.
To correct this, individuals with co-occurring disorders must have both their mental health and substance use disorders treated in harmony. Treatment for both mental health and substance use disorders may include rehabilitation, medications, support groups, and talk therapy.
But forcing this treatment upon an individual with a co-occurring disorder by evoking Kendra’s Law – and expanding it – is inhumane.
Kendra’s Law should be evoked as a last resort solution, not as a city-wide mental health solution. This fundamental misunderstanding about the impact of Kendra’s Law or AOT on increasing mental health care access, has historically led to significant racial disparities throughout the state. According to a report from the NYS Office of Mental Health, minorities are more likely to be the recipients of court orders which compel treatment or medication. And people who have been hospitalized previously, don’t have any history of violence are often the targets of Kendra’s Law.
It is my firm belief that this law creates obstacles to quality mental health care by creating a fear of forced treatment, and fraying a person’s trust in the health care system. Being forcefully hospitalized is one of the most traumatic things an individual can experience. A family member of mine went through it three times when they were in college due to being in a mental health crisis, and being confronted by an officer, instead of a mental health professional, did not remedy the situation, but intensified it.
Instead of finding relief during their hospitalization, for the first twenty-four hours they sat on a stretcher in the hallway waiting for an open room getting little to no sleep. When they got into a room and were admitted into the behavioral health unit, they were lumped in with patients of varying mental illnesses. There was chaos in the halls, screaming rang throughout the quarters, with medication shoved down their throat.
This created resistance to treatment for months afterward and shut my family member down from talking about the experience until after years of intensive therapy. While my family member did not have a co-occurring disorder, they were not given the qualitative treatment they needed. I am lucky that they are still here with us and that they are in recovery.
People who struggle with behavioral health issues are marginalized and face stigma that can lead to severe consequences. Mayor Adams, this policy perpetuates the belief that many people hold that individuals with mental health issues are dangerous. But in reality, they are more likely to be victims of crime and excessive use of force by the police than to cause harm.
Donna Lieberman, the Director of New York Civil Liberties Union, put it best, we are “playing fast and loose with the legal rights of New Yorkers.”
The NYPD are not trained to address mental health crises.
And I agree with Housing Works, who tweeted that the directive “seems like it boils down to letting the NYPD hospitalize people by force.”
We can do better. We should expand street outreach programs, OPCs, access to harm reduction, supportive housing, and investing in the behavioral health care system as a whole.
We need to pass the Safer Consumption Services Act (SCS Act) which allows local health districts and the New York State Department of Health to authorize community-based organizations to operate as safer consumption spaces (SCS), in which people can legally consume previously-purchased illicit drugs with supervision from trained staff.
This will provide NYC with more OPCs, which are community centers for individuals to educate themselves on harm reduction, seek information on rehabilitation, attend peer-led therapy sessions, meet with a social worker, and access basic needs.
Alexandra Nyman is a NYC resident
The writer is a peer advocate for the National Association on Mental Illnesses (NAMI) and serves as the Co-Chair on their Dual-Diagnosis Subcommittee
