Jordan Neely was “gentle, earnest and stable” during his 15-month stay in a Rikers Island mental-observation unit, staff members told New York magazine. He took his medications and engaged in treatment. Mr. Neely’s severe mental illness had left him jobless, homeless and increasingly unstable before a 2021 assault arrest. Now he seemed a perfect candidate for an alternative to incarceration, a residential facility, where he would continue to receive treatment.
But less than two weeks after his arrival, Mr. Neely, 30, walked out and went back to the streets. A few weeks later, he boarded a subway train in Manhattan. He began yelling that he was hungry and thirsty, that he didn’t mind going to jail, that he was ready to die. Allegedly fearing for the safety of other passengers, an ex-Marine named Daniel Penny grabbed Mr. Neely and put him in a chokehold. When he finally let go, Jordan Neely was dead.
Mr. Penny’s trial on charges of manslaughter and criminally negligent homicide is underway in Manhattan. The verdict will revolve around various particulars: whether Mr. Neely’s outburst put Mr. Penny and the other passengers in reasonable fear for their life; whether choking Jordan Neely was an appropriate response to that fear; what, if anything, other passengers said or did while Mr. Neely died.
But the verdict will also raise a far larger question: Are we finally so exhausted by the unpredictability and occasional violence of the insane in our streets, and so pessimistic about the possibility of a solution, that we accept that the best option left to men like Mr. Penny is to choke a frightening madman until he’s dead?
Madness — those serious and spectacular forms of mental illness that seem to separate the sufferer from the fabric of ordinary human life — has always posed a problem for society. It is exhausting to be a friend or a parent or a sibling or a spouse to somebody who’s lost his or her mind; you do not know what to do, how to help, how to stop worrying all of the time, how much more you can take. In public, the mad annoy, discomfit, inspire terror and sometimes terrorize. But madness is worst for the mad themselves.
I began to crack up as a teenager. I acted out in school. I became “difficult”: paranoid and aggressive and increasingly unsanitary. Convinced I was being poisoned, I tried to remove a lymph node with a knife. More than once, I became so threatening that the police got involved. At 24, I entered lifelong treatment for what would ultimately be diagnosed as schizoaffective disorder. After a decade of mood stabilizers, antipsychotics and other medications, I am stable and safe and able to live a largely ordinary life.
But I was lucky. I was lucky to have been born in a time with effective psychiatric medication, to not be among the 20 percent to 50 percent of patients who do not respond to that medication, or among those who simply cannot accept the need to take it. I was lucky to be able to afford it and the doctors and therapists who monitor its use. I had the luck to have made it far enough to get treatment without winding up on the street or in prison, or dead.
Many don’t have my luck. They are never diagnosed, or they are resistant to medication, or they cannot afford their medication, or they do not believe they need to take it. They drift in and out of 72-hour holds, returning to lives in constant chaos. They do not have the money or support or insight to stay on top of their own care. Our anemic system of welfare and social services cannot keep them from falling through the cracks. Even if a client can be stabilized, that is only a prelude to the endless work of maintaining an independent life. The mad are disproportionately likely to be poor, to be homeless and to be killed by the police. A leading cause of death among the seriously mentally ill is suicide.
We have never solved the problem of madness in public life because madness creates a dilemma between two principles of liberal society: the sovereignty of individuals and the collective right to public order. The mad have a right to public spaces and to live without being detained, harassed or killed because of a disease. But every other citizen has a right to move through public spaces without the unsettling intrusions and occasional outbursts of those who appear dangerous and who are not amenable to reason. It is not only the public who suffers from our negligence. The mad are as much a danger to themselves as they are to anybody else; they too have a right not to be left to deteriorate and die.
We want a solution that upholds both of these principles, but existing talk tends toward the broad. We need “more treatment” but “less stigma,” “more understanding” but also “real safety.” Some call for a return to institutionalization, but somehow without the horrific conditions and abuses that plagued the 20th century’s era of mass institutionalization. The proposals tend to stay broad because the particulars, as generations of policymakers, patients, citizens and activists have discovered, reveal a dizzying array of financial, political, medical and practical problems.
What would it really mean to return to the institutions? In the middle of the 20th century, before the advent of more effective psychiatric medications and before the bipartisan push to shutter many of the nation’s psychiatric hospitals, the United States, with around half the current population, had public mental hospitals in nearly every state and over 500,000 psychiatric beds; now there are only about 60,000 designated psych beds in the entire country. We would first need to build new institutions, and once built, the costs would only grow. According to one estimate, inpatient treatment for the average psychiatric patient costs between $500 and $2,000 per day. Even if we stipulate that the new asylums will need to spend only $1,000 per day per patient and assume that only 2 percent of the 15 million American adults with serious mental illness will need to be hospitalized at any given time, then simple math tells us that this would cost roughly $100 billion per year, more than the 2024 budget of the Department of the Interior.
Once established, these new institutions would need to maintain their funding in a political climate hostile to enormous new expenditures for the benefit of vulnerable populations. While civil libertarianism and scandal over the abuses of midcentury psychiatry both played a role in deinstitutionalization, much of the political muscle came from those like Ronald Reagan who were always eager to cut government spending — and still are. New asylums would face litigious, even extralegal, resistance by patients and activists opposed to the type of long-term involuntary holds that they helped end last century. At the very least, these new institutions would need to avoid the kind of dysfunction and scandal that would give these activists another winning case.
After deinstitutionalization, “community care” outpatient services were supposed to allow the seriously mentally ill to receive support while living ordinary lives. Such a model remains the goal of many activists and NGOs. But every attempt has faltered, with systems underfunded and caseworkers overloaded, patients slipping through the cracks or just slipping away. Like new asylums, an adequate community care system would require enormous funding for which there has all too rarely been enough political interest without aggressive litigation. Adequate community care would require subsidies for doctor’s appointments, medication and even housing. Most of all, it would require extraordinarily competent social workers — if they could be found — capable of keeping track of manageable caseloads, making excellent judgments about their clients’ needs, risks and prognoses, and doing all of it with the skills necessary to ensure the cooperation of patients without resorting to involuntary treatment.
Universal health care would of course be the most potent policy intervention for the mentally ill, but after a brief period of unfulfilled possibility, it has drifted farther to the periphery of the American political imagination.
What of a middle ground: community care for a majority of patients, like me, who can manage their lives with help; involuntary institutionalization for those in crisis, and only for the time it takes to stabilize them? The trouble begins when we remember that this is the system we have now. As always, the immediate trouble is financial: We have hospitals and outpatient services without the money or staffs to function and no feasible political path to adequate funding.
Even if this mixed system were ideally funded, we would still need to decide precisely who we commit. How long can we hold them? If permanent hospitalization is too long, are 72-hour holds too short? Can they be compelled to take medication and stay on it? What happens if they leave and fall into crisis? Do they get held longer the next time? It is easy to say we will commit only those who “really need it,” but who really needs it has never been reliably determined.
Err on the side of patient’s rights, and another Jordan Neely is inevitable. Err on the side of caution, and the system of civil rights violations, warehousing and abuse will follow. We have tried for a long time to answer these questions, and the answers have only ever ended in tragedy, overcorrection, new tragedies and backlash.
This is all to say: There are many solutions, but none are foolproof, and none would survive our existing moral and political reality.
If we are unwilling to violate our commitment to individual dignity, or our commitment to public safety, we must be willing to commit enormous sums of money in service of complex expansions of our medical welfare state perpetually inclined toward austerity. The alternative is the current nightmare: the fear and desperation and pain of the public and of patients alike, punctuated sometimes by lifeless bodies in New York subway cars.
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