Bill de Blasio will leave his successor a legacy of increased expectations on mental health. Michael Bloomberg had no distinctive mental health strategy. De Blasio, by contrast, sought ownership of mental health through his ThriveNYC initiative. In addition to being an ineffective policy—as the drumbeat of mental illness-related violence attests—Thrive was an imprudent one. With Thrive, de Blasio claimed responsibility for a wide range of mental-health problems beyond just dangerous psychosis while also de-emphasizing the obligations of other players in the public and private sectors.
New York will never get anywhere on mental health while the mayor is expected to do it all and do it alone. Addressing untreated serious mental illness, and the violence that too often attends it, is not the sole responsibility of city government. The election of a new mayor makes possible a reset on mental health, one that should entail a judicious rebalancing of the obligations of the mayor and city council, the state and federal government, and the nonprofit sector.
Start with the city council. ThriveNYC was as much a failure of oversight as execution. In the wake of starkly critical press coverage, several city councilmembers talked tough about Thrive’s cost, vague metrics, and inattention to serious mental illness. But Thrive is still thriving: de Blasio has continued to increase its funding and given its programs new life by rebranding them. The next city council should not content itself with stern denunciations to reporters or during hearings. They should focus on substantive metrics such as pushing down the rate of mental illness among the homeless and city jail populations. One likely new councilmember, Erik Bottcher, built his 2021 campaign around a serious commitment to treatment of serious mental illness. The next city council speaker should give him the chair of the Committee on Mental Health, Disabilities, and Addictions, if Bottcher wants it.
Even more important than the city council is New York State government. As of May, the five boroughs are host to 1,023 non-forensic adult beds run by the state’s Office of Mental Health. That represents an 18 percent reduction since April 2014. In the 1980s, Mayor Ed Koch blamed street homelessness on Governor Mario Cuomo and state government for recklessly shutting down psychiatric hospitals. Though the war between de Blasio and Andrew Cuomo was, if anything, more intense than between Koch and Mario Cuomo, de Blasio never made state bed cuts a major point of contention. As a result, Cuomo never faced as much blame for subway pushings as he should have. In a 2018 report, I showed how state bed cuts coincided with increased mental health-related pressures on local service systems such jails, shelters, and hospitals.
The federal government’s main mental-health responsibility is fiscal. Medicaid is the nation’s largest mental-health funding program, but it has never paid for care for adults in specialized psychiatric hospitals. This so-called Institutions for Mental Disease Exclusion has, for too long, encouraged states to under-invest in hospital-based care. The next mayor should work with the local congressional delegation to repeal it.
In June 2021, Eric Adams told City & State, “My administration will increase the number of inpatient psychiatric beds.” To make good on that commitment, New York’s likely next mayor must bring pressure to bear not only on state and federal partners but also on nonprofits. General hospitals run by nonprofit health systems, such as New York Presbyterian, remain important providers of inpatient care. But their commitment has been wavering, as shown by a 2017 Independent Budget Office report and protests over the planned closure of Allen Hospital in Inwood. Presuming he wins the mayor’s office in November, Adams should make clear to local health systems that the city needs their continued commitment to inpatient psychiatric care.
The mayor will also need to work with district attorneys and the court system. Mental-health courts operate judicial-monitoring programs for mentally ill people charged with a crime but capable of living safely in the community given appropriate supervision. Those who fail to satisfy the terms of their court-mandated treatment regimen face the threat of prison. In a “defund-the-police” climate, many progressives insist that only social services professionals can appropriately deal with social problems such as mental illness. They are mistaken. Leadership on mental health requires embracing the idea that judges and prosecutors, not just social workers, can play a constructive role in rehabilitating broken lives. Though mental health courts fall ultimately within the jurisdiction of district attorneys, the city could provide resources for housing and programs requisite for the mandated treatment regimens.
Lastly, there’s Kendra’s Law, an evidence-based practice that mandates court-ordered treatment for the mentally ill. To his credit, de Blasio increased use of Kendra’s Law through most years of his mayoralty. But since 2018, the numbers of court-order recipients have ticked down. The next mayor should reverse that trend. Adams, encouragingly, called for “Strengthened use of Kendra’s Law” in his platform. Expanding use of Kendra’s Law will require a formal outreach program to identify people who could benefit from it, such as those leaving jail and living in homeless shelters.
The city could also launch a public education campaign for families of mentally ill individuals to explain how Kendra’s Law could help. New York needs a more efficient way—other than a catchall mental-health help line—to bring people who need enhanced supervision to the attention of policymakers who can provide it.
At present, New York has no shortage of resources to devote to mental health. Nor does the city lack support for reform, given Thrive’s failures and ongoing public disorder. What the city does lack is an excuse for not doing better by the mentally ill.
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