If severe mental illness, untreated, underlies the feeling of encroaching anarchy and menace around the homeless encampments of San Francisco or in the subways of New York City, then the remedy appears obvious. Let’s rescue those who, as New York’s mayor, Eric Adams, says, “slip through the cracks” of our mental health care systems; let’s give people “the treatment and care they need.”
It sounds so straightforward. It sounds like a clear way to lower the odds of tragic incidents occurring, like the chokehold killing of Jordan Neely, a homeless, psychiatrically troubled man, or the death of Michelle Alyssa Go, who was pushed off a Times Square subway platform to her death by a homeless man suffering with schizophrenia. Improving order and safety in public spaces and offering compassionate care seem to be convergent missions.
But unless we confront some rarely spoken truths, that convergence will prove illusory. The problems with the common-sense approach, as it’s currently envisioned, run beyond the proposed solutions we usually read about: funding more beds on hospital psychiatric wards, establishing community-based programs to oversee treatment when people are released from the hospital and providing housing for those whose mental health is made increasingly fragile by the constant struggle for shelter.
The most difficult problems aren’t budgetary or logistical. They are fundamental. They involve the involuntary nature of the care being called for and the flawed antipsychotic medications that are the mainstay of treatment for people dealing with the symptoms of psychosis, like hallucinatory voices or paranoid delusions, which can come with a range of severe psychiatric conditions.
Existing laws in almost all states allow for mandatory care when a person is likely to cause “serious harm,” in the phrase of New York’s statute, to self or others. But many people view existing laws and implementation as too weak. Catalyzed by public fear, the effort now is to widen the net.
In California, at Gov. Gavin Newsom’s urging, the State Legislature last year passed the CARE Act, to be fully in place next year. The law has a soft name but is meant to broadly expand the use of court-ordered treatment, with antipsychotic drugs an essential element in the program.
In New York City, Mayor Adams has led a major push that would lower the standard for first responders to strap someone to a gurney, load them into an E.M.T. van and take them to a hospital for psychiatric evaluation and possible commitment, against their will. He would also make it easier to channel someone into court-mandated outpatient treatment.
These changes are couched in the language of fellow feeling. “It is not acceptable for us to see someone who clearly needs help and walk past them,” Mr. Adams has said. “We can do much more to help those among us in a severe mental health crisis, even when they are unable to, by no fault of their own, recognize their own needs.”
The mayor’s rhetoric refers to a psychiatric condition known as anosognosia — the state of being too sick, too far beyond reason, to recognize one’s own mental illness. It’s a diagnosis worth much debate, because it can be applied to anyone who doesn’t agree with a psychiatrist’s finding and can result in people being denied any real say in their own care. But it isn’t necessary to question anosognosia in order to question mandatory treatment. Because even if involuntary care may be warranted, the question remains: Does it work?
Imagine being cut off from society by a tormented psyche and extreme poverty and then being hauled off to an emergency room, forcibly injected with a powerful drug like Haldol and held on a locked ward until being dispatched into a compulsory outpatient program. Will this set the stage for a stable life? Or will it add to a person’s trauma, sense of isolation and lack of agency — and lead to their slipping away from whatever program they’re ordered into and back toward dire instability? For a few, such intervention may be a positive turning point. But that’s not the likely result.
The New York City chapter of the National Alliance on Mental Illness — the country’s largest organization representing the mentally ill and their families — has protested on City Hall’s steps against Mr. Adams’s efforts to loosen standards for mandatory care. The New York City Bar Association takes the same position, and the World Health Organization has published guidance to eliminate involuntary psychiatric treatment altogether, because, according to Michelle Funk, who leads the W.H.O.’s work on mental-health policy, “Involuntary treatment can harm a person’s mental and physical health, exacerbating crisis situations, damaging relationships with the clinicians, family members and others involved in coercive measures and driving people away from the mental health care system.”
Compulsory care is deeply problematic in itself, but is made more so by the medications at its core. This isn’t to suggest that antipsychotics should not be prescribed for people enduring psychosis. It is to say that the drugs shouldn’t be considered — as they tend to be now — the required linchpin of treatment. Antipsychotics probably reduce hallucinations and delusions for around 60 percent of those who take them, but the science around their efficacy is far from definitive and some studies (though not all) indicate that long-term maintenance on the drugs may worsen outcomes.
Science hasn’t made great strides in antipsychotics since the drugs were first introduced seven decades ago. Their lack of precision remains largely the same, and because the drugs affect metabolic systems as well as dopamine pathways throughout the brain, they often have profound side effects: mental torpor, major weight gain, tics, spasms and a condition called akathisia, an overall jitteriness, as if a mad puppeteer is fighting perpetually for control of the person’s body.
Commonly, people abandon their antipsychotic drugs, whether they’re in mandatory treatment or the most sensitive, attentive voluntary programs. This is generally attributed to anosognosia and the disorganization that can come with mental illness, but it might well be seen as an outcome from the weighing of pros and cons.
In any case, our current direction, toward more involuntary, medically centered care, probably won’t get us what we wish for: safer public spaces and fewer lost people.
We’re going to have to think less fearfully and more creatively, genuinely seeking the counsel of people who’ve learned to cope, in varied ways, with their psychiatric conditions. Beyond the bottom line of adequate housing, we’ll need to embrace approaches that may seem hazy in contrast to the chemistry of pharmaceuticals, but that can be the best hope for recovery. This will mean funding and fostering the kinds of supportive communities like Fountain House and the group meetings of the Hearing Voices Network, which combat isolation and despair with an emphasis on sharing experiences and solutions, but that are very few and far between even in a city like New York.
And it will mean coming up with new methods of care, partly by entrusting positions of leadership to those who’ve lived meaningful and flourishing lives with mental illness. By doubling down on existing methods, we’re only beckoning more failure.
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