Last November, Adams, citing a “crisis we see all around us,” announced at a press conference that homeless people with mental illness would be removed from the streets and the subways, against their will if necessary, by the police and other city employees. Advocates were outraged. Norman Siegel, the former head of the New York Civil Liberties Union and a longtime friend of the Mayor, said, “Just because someone smells, because they haven’t had a shower for weeks, because they’re mumbling, because their clothes are disheveled, that doesn’t mean they’re a danger to themselves or others.” Rumors spread quickly. Were the police about to start rounding up people who simply appeared to be mentally ill? How many were going to be detained? Two weeks later, lawyers sought to halt the initiative. In a courtroom downtown, an attorney for the city, who was defending the Mayor’s plan, said, “As far as anyone in this room knows, the initiative hasn’t changed anything.” The judge asked, “So the purpose of the press conference was to do what?”
“To announce the fact that the Mayor is taking the initiative of providing further guidance to the agencies about what is permitted under current law so that they can take action to protect New Yorkers under circumstances that the law permits.”
Adams’s policy, in other words, was more of the same.
In 1987, Mayor Ed Koch announced a broad interpretation of New York state law that permitted him to hospitalize the “loonies” and “crazies” around town. In the decades since, police and E.M.S. workers have regularly transported homeless people with apparent mental illness to hospitals against their will. That’s just part of the job: violent crime, parking tickets, heart attacks, the unsheltered woman in a wheelchair at Penn Station who is taken to Bellevue every few months after creating a public disturbance. The man with four large black suitcases who is picked up for zigzagging through traffic in Brooklyn and sent to the psychiatric emergency room at Kings County Hospital. The woman with schizophrenia who believes that the French government bought a church on Fifth Avenue and granted her the legal right to live there. One E.M.T., who has worked on ambulance crews across the city for the past twenty years, told me, “If the person is out of their mind, if you can see the person is not all there, the police will call for us, and we’ll come and take them.” (In the course of reporting this article, I interviewed dozens of E.M.T.s, paramedics, police officers, nurses, social workers, emergency-room doctors, and inpatient psychiatrists, most of whom requested anonymity in order to speak openly about the people in their care.)
Here’s how it happens. An E.M.T. and her partner park the ambulance—cops call it “the bus”—and evaluate the scene for safety. Does the individual have a weapon? Where’s the nearest egress? Then she’ll put on a pair of purple nitrile gloves and make a cautious approach. She’ll say, “What’s going on today, sir?,” or “Ma’am, how are you feeling tonight?” The person might respond with a mumble, a shout, or the formality you’d expect in a job interview. Often, the person will say, “I don’t want to tell you my name,” so the E.M.T. will smile and offer her own. She’ll say, “You’re not in trouble. I just want to know why you’re standing in the middle of the road. Can you come with me to the sidewalk, please? I’m here to listen.” Or maybe the person is already ripping the hair from his head and trying to escape the encounter by tossing the E.M.T.’s stretcher into the street. In that case, a paramedic can use a cotton sling to tie the patient’s wrists to his ankles and inject a drug, such as the sedative midazolam or the anesthetic ketamine. But not every ambulance crew has a paramedic. One might be ten or twenty minutes out, so, in the meantime, the E.M.T., who isn’t allowed to inject those drugs, will have to get creative. “You want cake? You want cookies? You want a cigarette?” Lies and threats, carrots and sticks; anything to get them on their way to the nearest hospital. The E.M.T. told me, “I don’t want to use the word ‘manipulative,’ but you have to figure out a way to just fucking get them in the ambulance.”
At the hospital, the patient is evaluated by a team of nurses and doctors in the emergency department. In New York City, this happens seventy thousand times a year. A little more than half of these patients—the ones in the worst shape—are then taken to the psychiatric unit. The hospital’s job is to evaluate, stabilize, treat, discharge. Just as you don’t depart the I.C.U. while you’re having a stroke or bleeding out, you don’t leave the psychiatric unit while you’re in the throes of psychosis. Some people stay for months before being transferred to a state-run psychiatric hospital; others are discharged after only a few days, or are never admitted at all. Every day at Bellevue, the largest city-run hospital, there are usually about five or six patients downstairs, in the psychiatric emergency department, waiting for a bed. The average stay in the psychiatric unit is thirteen days. (One reason hospitals discharge people so quickly is that there are not enough inpatient psychiatric beds; high-quality psychiatric care is not as profitable as specialized spinal surgeries and hernia repairs.)
Almost every patient who comes in this way has a serious underlying condition—bipolar disorder, major depression, schizophrenia—that even a couple of weeks surrounded by nurses, doctors, and social workers cannot fix. In the late eighties, following a legal challenge to Koch’s involuntary-hospitalization initiative, one judge described the city’s approach as “revolving door mental health—that is, forcibly institutionalize, forcibly medicate, stabilize, discharge back into the same environment, and then repeat the cycle.” Thirty-five years later, the vocabulary that’s used to describe the city’s mental-health-care system hasn’t changed. “It’s a revolving door,” a cop who was working an overtime shift on a subway platform in Clinton Hill told me. “We bring them in, and the hospital just discharges them!” She and her partner both had a few streaks of gray in their tidy black hair, and wore matching N.Y.P.D. beanies. The second cop sighed. “In and out,” she said. “I’m not sure anything we do is going to help if the hospitals keep letting them go.”
The hospitals keep letting them go because they often have to. Patients can always refuse treatment or ask to be released; compelling someone to stay requires a court order from a judge, and the legal standard is high. The hospital must prove that the patient poses an immediate threat to himself or to others, and that his judgment is so impaired by his illness that he doesn’t even understand that he needs help. A psychiatrist at a city-run hospital sketched out a hypothetical scenario: Two men with paranoid schizophrenia arrive in the back of an ambulance, escorted by police. Both are living at homeless shelters, and neither has eaten in about five days. A doctor asks each man, “Why are you starving yourself to death?” The first says, “The voice of God is commanding me to go on a hunger strike!” The second replies, “The food at the shelter is disgusting. I’ll eat when I have money to buy something good.” Both men have a serious mental illness, but only the first will be made to stay at the hospital against his will. The second can walk out the door.
On a recent Tuesday morning, I visited the second floor of a shabby building on Rockaway Avenue, in Brownsville. Social workers were sitting in blue office chairs, surrounded by large Rubbermaid containers filled with granola bars, body lotion, sweatpants, toilet paper, detergent, and chocolate-chip cookies. The group is one of thirty-one Intensive Mobile Treatment teams, which care for the city’s “frequent fliers” and “heavy hitters”—the four hundred or so men and women who are regularly and repeatedly admitted and discharged from city and state psychiatric units, or released from Rikers, where a fifth of incarcerated people have been diagnosed as having a severe mental illness. I.M.T. teams help people who have a history of chronic street homelessness and violent behavior; a psychiatric diagnosis is not on the list of admission criteria, but almost all I.M.T. clients have one.
Cartoon by Hartley Lin
Just after ten o’clock, someone turned down the volume on a TV in the office, and the team’s leader, Lauren Schultz-Kappes, who wore bluejeans, yellow Nikes, and a silver heart necklace, began the day by giving an update on their twenty-seven clients. Tony was living in a shelter and recently went to a dentist appointment. J. B. Fresh had been staying at a nursing home and didn’t like the food. Batsheva was transferred to a state-run hospital on Staten Island. Alex requested a Russian Orthodox Bible with large type and has become obsessed with juice. Markease was scheduled to receive his psychotropic medicine via intramuscular injection at a veterans’ hospital. Merisa had court that afternoon. “She didn’t seem to understand why it was wrong for her to pepper-spray the emergency room,” Schultz-Kappes explained. “And she said, ‘Why’s it such a big deal?’ So, we’ll see how court goes today.” The list went on: Fantasia was a little internally preoccupied again. Casper was still street homeless. Raymond was still missing. Rene was doing all right. Marwan was back at Bellevue. “He’s a weird mix of really lucid at times and then really not understandable,” one of the social workers said.
Schultz-Kappes added, “And he’s really loud.”
New York has funded an alphabet soup of outreach groups and teams—M.C.T., B.R.C., S.O.S., ACT, B-HEARD, C.U.C.S., A.O.T., FACT, I.M.T.—each of which is different in origin, scale, and scope. A person with a mental illness is more likely to be the victim of a crime than to commit one, but every so often the script gets flipped. It’s in those moments that local and state politicians feel compelled to talk about change. Assisted Outpatient Treatment was announced, in 1999, after a schizophrenic man, who had been in and out of psychiatric care and had stopped taking his medication, pushed a thirty-two-year-old woman named Kendra Webdale in front of an N train. Webdale died, and that year the state passed Kendra’s Law, which allowed a court to mandate outpatient treatment, including psychotropic medication. (Around three thousand patients are currently under such orders.) City Hall launched I.M.T. teams in 2016, after a person with a mental illness killed a thirty-six-year-old woman named Ana Charle, who ran a homeless shelter in the Bronx.
In 2022, there was another horrific crime, another person failed by the system. Martial Simon, whose medical records included dozens of psychiatric hospitalizations, indicating that he was a serious threat to himself and to others, walked up to a forty-year-old woman named Michelle Go one morning and pushed her onto the subway tracks, where she was run over and killed by a train. Before the incident, Simon had been in the emergency room at Queens Hospital Center. A psychiatrist who treated him at another hospital told me, “If someone had just read his chart, it would have flagged for them ‘Hey, this guy is the real deal.’ ” Instead, clinical staff decided that he was malingering, or faking his symptoms, and told him to leave.
The goal of most outreach teams is to get a patient from one point of care to the next—a complicated and difficult process. (A hundred thousand city residents with severe mental illness are not receiving any mental-health treatment.) Sometimes, when a person gets discharged from a hospital or released from Rikers, he’ll leave with a pill bottle filled with thirty days’ worth of Abilify, Ativan, or Haldol. Often, though, a person leaves with only a prescription, and it is not uncommon for it to be sent to a pharmacy that’s far away from where he wants to end up—to a Walgreens in the Bronx, for instance, even though he is staying in a homeless shelter downtown. Several people who have stayed in shelters told me that, if they don’t show up for a night to claim their bed, staffers throw away their medicine—along with everything else they own. (The city’s Department of Homeless Services told me that, when someone does not return, shelters store their belongings for at least seven days.)
The System That Failed Jordan Neely
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