Lamar Brown was one of the people some New Yorkers instinctively flinch from on the subway.
Living with schizoaffective disorder, talking to himself and surrounded by trash bags full of his possessions, he would ride the trains for hours. He spent years living in the subway system and on the streets.
Early last year, he was spotted on a train in Midtown Manhattan, yelling and muttering, and paramedics took him to a hospital psychiatric ward. It was a trip he had made before, one that mentally ill, homeless New Yorkers made involuntarily more than 1,500 times last year.
Typically, hospitals treat and medicate people like Mr. Brown, 40, for a few days or weeks, until they are temporarily stable enough to be discharged. Then they are released to a shelter, a safe haven (a shelter with fewer restrictions) or back onto the street. They often stop taking their medication and quickly lose the ground they gained at the hospital and slide back into the depths of their illness.
This time, though, after three weeks in the hospital, Mr. Brown was not released. He was sent to a locked ward in a hulking state-run psychiatric institution on a small island off Manhattan. He spent more than seven months there, left last fall and has been stably housed ever since.
The program he was placed in is known as the Transition to Home Unit. It has a simple but daunting mandate, said Dr. Caitlin Stork, the psychiatrist who designed it.
It takes mentally ill men and women who have languished for years on the city’s streets and subways — the public face of New York’s seemingly intractable homelessness crisis — and tries to “really get at the root of what is keeping them on the street,” Dr. Stork said.
Then it treats those patients until they are able to move directly into permanent supportive housing, which offers social services on site.
Someone in Mr. Brown’s condition might be less likely to be involuntarily hospitalized under the administration of Mayor-elect Zohran Mamdani, who is skeptical of treating people against their will.
In the program, housed at the Manhattan Psychiatric Center on Wards Island, patients see a psychiatrist daily. Their medications are tweaked again and again as doctors hunt for the combination of drugs that will be able to stave off their delusions without tranquilizing them into a stupor.
They attend psycho-education classes to learn about their diagnoses, cognitive behavioral therapy to help manage the voices in their heads, and “basic skills” classes to relearn the elements of self-care after long periods of living rough.
The track record of the 50-bed program, which is run by the State Office of Mental Health, is fairly encouraging, considering that it is aimed at those who have proved hardest to help.
Since the program began in 2022, about 120 people have gone through it and nearly all of them have “graduated” to permanent housing. When the state followed up with a sample of the graduates, it found that three-quarters of them remained housed three months later, and a little more than half remained housed after a year.
Mr. Brown entered the program in late February 2024 and remained for more than seven months. Last October, he moved to a studio apartment in a supportive housing building on the Upper West Side.
He has been getting career counseling from the Center for Urban Community Services, a social-services nonprofit. In recent weeks, he has had four interviews for jobs doing cleanup or stockroom work, or in food sales. He is hoping for a call back from the Bronx Zoo.
“I would say things have been going on the bright side,” he said in an interview last week, one in a series of conversations over the past nine months. “I’m very close to a job. Everything is looking bright.”
Mr. Brown still leads an intensely interior life — “I’m kind of in my zone all day,” he said in April — but he is stable and says he is taking his medication consistently.
He has mixed feelings about his journey through the psychiatric system. He accepts his diagnosis, but does not believe he needed to spend months in a hospital. He said being in the Transition to Home Unit was “all right” but that its staff had pressured him to take medications. “They said the treatment was necessary to get the apartment,” he said.
The Shadow Boxer
The circumstances that led Mr. Brown to the T.H.U. were unusual, but in a way, they were emblematic of the approach to mental illness and homelessness advocated by New York’s outgoing mayor, Eric Adams.
In 2022, Mr. Adams announced that the city would involuntarily hospitalize people on the streets if mental illness left them unable to meet their “basic needs,” even if they were not threatening to harm themselves or anyone else.
The policy shift, which was based on guidance from the state, was welcomed by some New Yorkers but opposed by civil libertarians and others who argued that it violated people’s constitutional rights.
The types of people the policy would help, the mayor said, included “the shadow boxer on the street corner in Midtown, mumbling to himself as he jabs at an invisible adversary.”
That image came from the mayor’s senior adviser for severe mental illness, Brian Stettin, who said he had based it on a man he regularly encountered making bizarre speeches into a toy microphone or throwing tight punches at the air.
In February last year, Mr. Stettin saw a subway passenger sitting with several trash bags and jabbering, his possessions spilling across the seat. He did not immediately recognize the man, and emailed a mental health team that dispatches nurses and police officers into the subway.
“Guy right now on downtown C,” Mr. Stettin wrote. “Just leaving 59th, yelling/muttering to self, huge amount of stuff.”
The man got off at 34th Street and started rapping into a toy microphone. Mr. Stettin realized he was the shadow boxer. It was Mr. Brown.
Quieting the Voices
Mr. Brown said he had been “mingling in the street and then in shelters” since his 20s. But in recent years, he said, when outreach workers approached and offered a shelter bed, he would decline.
Like many people who choose to sleep in streets and subways, Mr. Brown said he had found homeless shelters — where dozens of people sleep in large dorm rooms — chaotic and sometimes dangerous. “I’d ask them about apartments, and they’d say I had to be in shelter for six months or nine months, and I didn’t trust the shelters,” he said.
When he was picked up that day on 34th Street, Mr. Brown was taken to Bellevue Hospital, home to the biggest city-run psychiatric ward in New York. After three weeks, his psychosis had only partly abated.
But because of limited space and other factors, three weeks is as long as New York’s public hospitals typically hold psychiatric patients. Bellevue needed Mr. Brown’s bed for the next person in crisis.
A bed had opened at the T.H.U., however, and Mr. Brown met the criteria. He had serious mental illness, he was medically stable, and he had a long history of homelessness and of cycling in and out of care.
When he arrived, he was still conversing aloud with the voices in his head. He had grandiose fantasies and told doctors that if they discharged him, his fans would support him.
The doctors added one antipsychotic medication and increased the dosage of another. They gave him mood stabilizers. They watched for side effects. Each change took days to see results. Finding the right cocktail took more than four months.
As Mr. Brown gradually grew more grounded and social, he taught fellow patients and staff members to play cards and presided over spades tournaments.
He filled notebook after notebook, first with strings of numbers and music and then, as he improved, with journal entries about his hopes for life after hospitalization.
Debating the Benefits
Dr. Stork, the clinical director of the psychiatric center, said that one of the most helpful things the T.H.U. offers patients is extra time in a safe environment.
“Someone who has had that ‘revolving door’ experience with care has a severity of illness that takes a bit longer to stabilize,” she said. And getting into supportive housing often takes months.
The T.H.U. is an expensive undertaking: A six-month stay costs taxpayers about $140,000. But the daily price tag — about $770 — is far less than the cost of an acute-care hospital bed or a spot at Rikers Island, the city jail complex where mentally ill homeless people often end up. The state plans to open 75 more T.H.U. beds at Creedmoor Psychiatric Center in Queens in 2027.
The unit is one of a handful of so-called transitional housing programs that work to ready people with severe mental illness for permanent housing. The city runs two similar programs, though they are voluntary: There are 60 beds in “extended care units” at city hospitals that keep patients for up to four months, and 46 beds in a heavily supervised outpatient residence called Bridge to Home, which is overseen by Bellevue and houses people for one year.
Some advocates for people with mental illness are generally opposed to involuntary hospitalization.
“I would not overleverage what hospitals are capable of doing,” said Harvey Rosenthal, the chief executive of the Alliance for Rights and Recovery, though he added that there can be benefits to hospitalizing someone for more than just a few days.
“What do you think they have at a hospital? They have medication and groups,” he said. “To keep people in them longer simply because they don’t have housing is not the way to go. It’s a poor approach to treatment and it’s a poor use of taxpayer dollars.”
But Scott Auwarter, a former assistant executive director at BronxWorks, a nonprofit that holds the city homeless-outreach contract for the Bronx and runs a shelter for mentally ill men, said the T.H.U. “filled a really important void.”
For a limited number of severely mentally ill homeless people, he said, “if it wasn’t for the fact that they could be held involuntarily for an extended period of time, they’d either be dead or still out on the street.”
Mr. Mamdani vowed during his campaign to ensure that “involuntary hospitalization — which often fails to put people on a path to recovery — is rare and a last resort.” His plan is to build more housing and further expand voluntary, peer-led treatment programs. His transition team declined to answer questions about the T.H.U.
Mr. Stettin, who like his boss, Mr. Adams, is leaving City Hall at year’s end, said he worried that Mr. Mamdani would return to a policy “of not intervening involuntarily until a person presents an imminent risk.”
That would mean, he said, “that if we encounter somebody in the condition that I saw Lamar in, who’s clearly on a road to self-destruction but hasn’t reached the end of it yet,” the system would wait for the person to accept help — at which point it could be too late.
Mr. Brown’s apartment on West 98th Street is small and no-frills, but comfortable. He spends part of each day writing songs, filling sheet-music notebooks with his own private system of notation.
He said last week that he was working on a new song. “It’s called ‘Black Swan,’” he said. “It’s about freedom, love and sacrifice.”
Last month, Mr. Brown celebrated Thanksgiving with his mother and aunt in New Jersey for the second year in a row, after years of spending the holiday at soup kitchens or riding the trains.
“Turkey, barbecue chicken, a lot of soul food, macaroni and cheese, black-eyed peas, potato salad,” he said. “It was a good Thanksgiving.”
Andy Newman writes about New Yorkers facing difficult situations, including homelessness, poverty and mental illness. He has been a journalist for more than three decades.
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