Earlier this week, New York City Mayor Eric Adams made a speech about how he refused to ignore people living on the street who appear to be struggling with mental health issues. He acknowledged the need for long-term supports, such as permanent housing with attached social services.
But the centerpiece of his announcement was a policy shift empowering police and street outreach teams to bring more New Yorkers to the hospital for psychiatric evaluation — against their will if necessary.
Pointing to state guidance released in February from the New York Office of Mental Health, on the same day he and Gov. Kathy Hochul launched a subway safety plan, the mayor said the standard for forcing someone to go to a hospital should be whether that person appears to be struggling with a mental illness and unable to meet their own basic needs — not just whether they are likely to hurt themselves or others, which was the previous standard.
But the new directive raises the question: What exactly happens when someone is taken to a New York City hospital against their will? The practice has long been in place for people considered threatening, and some in the mental health community say it often fails to leave patients better off – at times, even making things worse.
When a New Yorker arrives at a hospital emergency room, they must first be evaluated by a medical professional to determine if they should be admitted and given a bed. The goal of a psychiatric hospitalization is typically to stabilize someone in the short term — often with medication — and then connect them with long-term services in the community. But those working in mental health said both hospital psych units and community-based services in the city are already strained.
Even those who work in psychiatric hospital settings acknowledge that not everyone benefits from being hospitalized.
“The hospital isn't the place that magically fixes problems, especially a lot of these longer-term chronic issues,” said Dr. Craig Spencer, former director of global health in emergency medicine at New York-Presbyterian/Columbia University Medical Center who left this summer to join Brown University as an associate professor. “It may or may not improve their underlying condition… Maybe it'll help if they're not taking their medications, maybe it won't.”
Why involuntary hospitalization is easier said than done in NYC
While staffing and bed volume vary by hospital, employees at some city facilities said they are already facing serious capacity issues. Behavioral health staff at Metropolitan Hospital in Harlem have dealt with increased violence in recent years, which they attribute, in part, to staffing issues. Those at the public hospital who spoke to Gothamist earlier this year said sufficient support staff was particularly crucial with needier patients and those who might be prone to violence.
Meanwhile, more psychiatrists are needed both to evaluate whether someone should be admitted to a hospital in the first place and provide medication management during their stay. Involuntary admission requires at least two clinicians to assess the patient and agree, Spencer explained.
The new directive could send more people to city-run medical centers in the NYC Health + Hospitals system. Asked this week about how the policy might exacerbate existing staffing issues, City Hall spokesperson Kate Smart pointed to a $1 million loan forgiveness program that was announced in July to help recruit behavioral health staff to the public hospital system. Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, said at a panel hosted by Gothamist in June that it was becoming harder to recruit psychiatrists and psychologists, in part because of the growth of opportunities in telehealth.
Bed capacity may also pose a challenge, depending on where a person is dropped off. Statewide, hospitals cut about 12% of their psychiatric hospital beds between 2000 and 2018, according to a report from the New York State Nurses Association.
A psychiatrist at one NYC Health + Hospitals facility, who declined to be named because they are unauthorized to speak to the press, said this week that people sometimes remain in the emergency room waiting to be placed in a bed for days at a time. At the time they spoke to Gothamist, they said one person had been waiting at their facility for a week. But a psychiatrist at another public hospital in the city said they can typically place someone in a bed in a reasonable amount of time because they either have one open or have enough staffing to call around to other facilities.
At Columbia Hospital’s emergency room in Washington Heights, where Spencer worked, he said there were at times “dozens” of people waiting for placement “for at least days, many of them for weeks.”
“I don't want anyone to be walking down the street and feel unsafe because there's someone that does need mental health care that's unable to receive it,” Spencer said. “But at the same time, we need to think about what this means for hospital staff and for others that don't have the resources we need right now to deal with the current patients.”
About 1,000 psychiatric hospital beds were closed statewide during the pandemic to make more room for COVID-19 patients, and 850 remain offline, Gotham Gazette reported earlier this week, citing state-provided data. Half of those that remain closed are in New York City. Overall, the city had 3,991 inpatient psychiatric beds as of March, according to state data, but that figure included those that were not operational.
Hochul recently announced that two 25-bed psychiatric units dedicated to people who are homeless would be opened in state-run hospitals. One opened in Manhattan at the beginning of November and another is slated to open at a downstate hospital early next year, Crain’s reported. It’s one piece of the broader plan Hochul and Adams have been rolling out in response to concerns about subway safety.
Does hospitalization help or hurt?
People typically have their phones and clothes taken away during the hospital admission process and, especially if it’s involuntary, that could “make anyone really upset and feel unsafe and vulnerable,” Spencer said.
He added that at Columbia, staff often subdued patients with sedatives or physical restraint. “There are a lot of scenarios in which floridly psychotic patients do things that hurt themselves and hurt others,” he said.
Arvind Sooknanan, a New Yorker who has been hospitalized multiple times for symptoms of his schizophrenia, has described hospital psych units as “health jail.”
After hospitalization, the goal is generally to get patients longer-term care such as individual or group therapy, a psychiatrist to manage medication, social support programs, mobile treatment teams that will provide regular check-ins, or housing if someone is homeless.
“Let me be clear: When we hospitalize those in crisis, it will be with a sense of mission to help them heal and prepare them for an appropriate community placement,” Adams said when he announced his policy earlier this week.
But hospital workers said that’s not always possible.
“With the number of social workers that we have, they meet them on admission and they meet them on discharge and they do very little for them in between,” said one of the NYC Health + Hospitals psychiatrists who spoke anonymously. “Just simply because they don't have the time to do it.”
The city’s community-based services also have limited capacity. At the Jewish Board, a nonprofit that operates outpatient mental health clinics across the city, there is currently a 1,500-person waitlist for a therapist.
Dr. Jeffrey Brenner, the Jewish Board’s CEO, said that’s due to a high number of job vacancies at the organization because the level of reimbursement from both Medicaid and commercial insurance for these services makes it impossible to pay therapists enough.
His organization also operates assertive community treatment teams, which provide regular check-ins on people with mental illness and seek to engage them in services like mental health care. As of last month, about 800 people were on the waiting list for these teams, according to data the city provided to Crain’s New York Business this week.
Brenner said he is currently trying to launch a new team but is unable because of a lack of funding.
“I admire and appreciate the mayor putting his foot down and saying, enough is enough,” Brenner said. “Because to anyone who rides the subway or walks around the city, it's clear we're in crisis.”
But he said taking people to the emergency room as the default solution is not the answer. “You get traumatized by that,” he said. “It makes people actually less likely to cooperate with the treatments that we want.”
He said in addition to fully funding services for people with mental illness, the city should look into alternatives to traditional emergency rooms that have shown promise elsewhere in the country. He pointed to the more serene “empath” units that were initially developed in Alameda County, California, in 2013 before being rolled out in a handful of other cities across the country.
Adams has said that involuntary treatment will still be a last resort. But the mayor’s announcement has sown confusion among some with mental health conditions about their rights and what might happen to them on the streets or in a hospital setting.
At Fountain House, a clubhouse for people with serious mental illnesses, many members were alarmed by the mayor’s speech and concerned about how it would affect them, said CEO Ken Zimmerman. “Somebody just took me aside and said, ‘I'm sort of afraid of being tasered,’” Zimmerman said.
As part of his announcement, Adams also released a list of legislative changes he would advocate for at the state level. It included requiring hospitals to screen all psychiatric patients for assisted outpatient treatment — meaning treatment mandated by a court under Kendra’s Law – prior to being discharged.
Hearing that, Sooknanan, who is a board member at Fountain House, said it might make him think twice about going to the hospital – even for a nonpsychiatric medical issue.