DJ Jaffe joins Stephen Eide and Howard Husock to discuss severe mental illness and the deficiencies in mental-health services in New York City and across the country.
DJ Jaffe is the author of an important new book, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is executive director of Mental Illness Policy Org., a nonpartisan think tank that creates detailed policy analysis for legislators, the media, and advocates.
Stephen Eide is a senior fellow at the Manhattan Institute and author of a recent report, “Assisted Outpatient Treatment in New York State: The Case for Making Kendra’s Law Permanent.” His story in the Spring 2017 issue of City Journal, “Failure to Thrive,” dissects New York City mayor Bill de Blasio’s signature mental health initiative, ThriveNYC.
Howard Husock is vice president for research and publications at the Manhattan Institute and a City Journal contributing editor. His story in the spring 2017 issue,“Dreams of My Uncle,” tells the story of his schizophrenic great-uncle, who spent most of his 92 years in Ohio mental hospitals.
Howard Husock: Hello. I am Howard Husock, vice president for research and publications here at the Manhattan Institute. Today our topic is serious mental illness. Not a happy topic, but one of the most important ones facing American cities and American life generally. I am joined by two close associates of the Manhattan Institute. One, a senior fellow here, Stephen Eide, who has just written a major article for City Journal on Thrive New York, a plan developed by Mayor de Blasio here in New York to deal with mental health, and a major report on Kendra’s Law, which deals with assisted outpatient treatment for those suffering from severe mental illness. And, along with Stephen, DJ Jaffe, the author of an important new book featured here at the Manhattan Institute at a recent lunch, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. I would like to begin with you, DJ, and set the big picture and then we are going to move into New York as sort of a case study for what goes on at the local level. You talk about the severely mentally ill and you distinguished that diagnosis, if you will, from problems with mental health. Why do you think that is an important distinction?
DJ Jaffe: Well, 100% of the population can have their mental health improved, all of us. 18% have something that is in the Diagnostic and Statistical Manual. That is mainly minor depression, anxiety, ADHD, but there are 4% with a serious and persistent mental illness that dramatically affects their ability to survive and to provide for themselves. And it is these individuals who need help the most and also create consequences for the community. It is the most seriously mentally ill who wind up homeless, hospitalized, arrested, incarcerated, and sometimes violent.
Howard Husock: And what do we mean by the most seriously? What do they suffer from?
DJ Jaffe: Anything that dramatically impacts their ability to function, but the two most common ones would be schizophrenia and severe bipolar disorder that is resistant to treatment. And what they have is these people sometimes do not know they are sick when you see somebody walking down the street screaming they are the messiah, it is not because they believe they are the messiah, they know it. Their illness tells them it is so. It is called anosognosia, they don’t know they are sick, and they are a problem.
Howard Husock: And, Stephen, are these people that we see on the streets here in New York? There is a lot of concern about the homeless and, in your article, you talk about homelessness including this group of the severely mentally ill in the streets and are they other places? Where are they?
Stephen Eide: Well, especially on the streets, if you talk about you know, what is the rate of serious mental illness amongst the adult population in New York City, you are talking about 4% or so of the adult population. But they are 25% of the adult homeless shelter census and they are over 10% of the inmate population at Rikers. Rikers is the largest mental institution in New York State.
Howard Husock: And that’s a jail.
Stephen Eide: Right. It’s a jail, right. Rikers Island, yeah. So, and this is common, you find this in many jurisdictions across the nation. We have, you know, as we have deinstitutionalized the seriously mentally ill, we have moved away from the process of trying to treat them through inpatient long-term commitment, trying to treat them in the community, but what that has really meant is they are “treated” inside the homeless system and also the jail system.
Howard Husock: Right. So the mayor of New York has a plan called Thrive NYC, which is a very ambitious commitment to mental health. And yet in your article you see it as somehow at odds with treatment of the population that we have been discussing here with you and DJ. Explain that for us and explain whether it is representative as far as you understand it.
Stephen Eide: One way to think about what the mayor is trying to do at Thrive NYC is, de Blasio is critical of many things that Bloomberg did but he has always been positive on the public health stuff. Soda taxes…
Howard Husock: And Bloomberg is the former mayor of New York, Michael Bloomberg.
Stephen Eide: That’s right. So there was a big change under the de Blasio administration in many respects and public health de Blasio has always been positive. And what he wants to do at Thrive NYC is adopt a public health approach to mental illness. And that means two things in particular. It means a focus on kind of like public campaigns. These campaign ads on subways and so forth to tell people to set up hotlines to say everyone has a mental illness, please call if you have help. These are especially focusing on what they call the problem of stigma. The problem of stigma presumes that many people have mental illness but are afraid of being thought of as having mental illness to their friends and family and so they don’t seek treatment. The second thing that a public health approach to mental health means is prevention. We are trying to do everything we can to prevent serious mental illness from arising, sort of like you can imagine the way that we tried to prevent all sorts of infectious diseases from spreading back in the 19th century through investing in water infrastructure.
Howard Husock: And, DJ, by your lights, what is wrong with that? It sounds unobjectionable.
DJ Jaffe: It is a good sound bite, let’s invest in people early and we can prevent mental illness, but there’s no science behind it. Schizophrenia cannot be prevented, bipolar cannot be prevented, there will be a Nobel Prize that goes to the person who does that. Secondly, stigma is not a major barrier to care. It is far behind lack of access, it is too expensive, they don’t have transportation to it, you can’t get an appointment, you don’t believe you are ill. So, stigma is far behind all these other things in preventing the seriously ill from getting treatment. His approach basically says even on the ad campaigns, the ad campaigns say if you have anxiety or depression, call this hotline. It doesn’t say if you have schizophrenia, bipolar, or have been eating out of a dumpster because you think you are the messiah, call the hotline. They are drawing in people who don’t have serious mental illness and that is taking away from a focus on those who do.
Howard Husock: Is this distinct to New York?
DJ Jaffe: I am going out to California, and California and New York are the two poster children for this. New York is spending $850 million on Thrive New York City. California passed a 1% tax on millionaires that raises $1.8 billion dollars a year that is required to go to the seriously mentally ill and it is being diverted to pop psychology programs for all others.
Howard Husock: So, Stephen, the idea that the seriously mentally ill really have to be in treatment, probably including medication, even if they don’t want to be treated because they are under the illusion that they are not seriously mentally ill, you write about, in your new report for the Manhattan Institute on Kendra’s Law, how that is an approach to addressing that population. Could you explain it?
Stephen Eide: Yeah, you know when we are talking about the challenge that we face in terms of connecting the seriously mentally ill with treatment, you know no one is seriously talking about going back to the days of institutionalization when everybody, even you know, people with dementia, were housed in mental institutions. That’s not a practical solution, so inpatient commitment is an important part of the system, but that’s not going to be the kind of default solution like it used to be in the old days. What we developed in New York, well, as a result of legislation that was passed in 1990, is something called outpatient commitment, or assisted outpatient treatment. That is when you have individuals who have serious mental illness, we expect them to live in the community, but they have had trouble living in the community without supervision. They have not complied with treatment, they have been incarcerated, homeless, institutionalized. So you put them under a court-ordered treatment plan so that they live in the community but they have to comply with medication, counseling, other services. And so as long as they comply with that treatment plan, you know, everything is fine. But some people need a little bit of that nudge in order to live in the community.
Howard Husock: And has that been effective? Constructive?
Stephen Eide: Yeah for the sort of between 14 and 15,000 New Yorkers who have been in the program since the law was passed in 1999, very impressive outcomes. You know when we are talking about you know, why do we know we have a problem with serious mental illness in New York, well it’s because of these high rates of homelessness, incarceration, hospitalization. Among those big three indicators you see big drops for the cohort prior to entering Kendra’s Law, and in Kendra’s Law. Rough drops of about 60 to 70%, okay. So 25 to 30% - at a 25 to 30% rate, Kendra’s Law recipients were homeless or incarcerated. That drops down to about 10% when they are in Kendra’s Law. So, a big drop. And hospitalization down from basically 100% to you know, down 60%, so below 40%. So in terms of the outcomes that are really important to people that we are really looking to do something about, Kendra’s Law has been very successful.
Howard Husock: And so just real quick, what does it actually look like? I am not in an asylum, I am living in the community. How do I get this treatment? Who is responsible for it? How does anybody know that I am actually accepting the treatment?
Stephen Eide: Yeah, DJ do you want to take this one? Get set up?
DJ Jaffe: It is court-ordered, so somebody files a petition with the court. As a reality, most of the time that is a hospital making a discharge. And the court will order the person to be evaluated. They have to have a particular history of multiple arrests, incarceration, hospitalizations, or homelessness that were associated with going off treatment. The judge finds they meet all that criteria, that they have that past history. He can order them to be – or she – to be mandated and monitored to accept treatment while living in the community. I should also point out…
Howard Husock: Where do they get the treatment? That’s what I’m driving it.
DJ Jaffe: They are given a treatment plan. So not only is the patient ordered to accept treatment, but the mental health system is ordered to provide it. That is very significant because generally the community programs want to cherry-pick the highest functioning. So what Kendra’s Law does is it has the ability to over time focus a system on what it won’t voluntarily focus on, which is the most seriously ill. I should also point out that by doing this it cuts costs to taxpayers by 50% because it is lowering, Stephen pointed out, it is lowering the use of hospitals and jails which are much more expensive. Now the cost savings is a little touchy because who is it saving money? There is really no level of government that cares about saving money to taxpayers. They care about saving money in their budget…
Howard Husock: Right. So…
DJ Jaffe: …so the state to the feds or the mental health system to the criminal justice system, but for taxpayers it clearly saves.
Howard Husock: Right. And just remind us, who was Kendra, for whom the law was named?
DJ Jaffe: Kendra Webdale was living in New York and she was pushed onto the subway by Andrew Goldstein. Now, Andrew Goldstein had schizophrenia. He was repeatedly hospitalized, given treatment, repeatedly went off the treatment. Now, immediately before pushing her he had gone to a hospital and tried to get treatment. So a lot of people have said well this is really only the story of a hospital denying treatment. But had he been compelled to accept treatment he would not have needed that hospital care. I should also say that he has been interviewed in jail and says he wishes Kendra’s Law existed before he did what he did.
Howard Husock: Right. Is this a common theme that many of the horrific, high-profile crimes involve people with schizophrenia and bipolar disorder?
DJ Jaffe: Yes. Just today there was somebody released in, I think it’s Minnesota, was released out of a hospital and fifteen hours later killed his mom. It is acts of violence by the mentally ill are rare, even by the seriously ill they are rare. But by the untreated seriously mentally ill this is a problem that we can’t just bury our heads in the sand about. So it is a problem and much of the violence, most of it is not high-profile stuff that you see, it’s against family members. And frankly most of it isn’t even violence per se, it’s dangerous behavior, it’s danger to self. It’s dine and dash because you can’t get any food. It’s sleeping in public because you have no place to sleep. So there’s a whole level of crime. And a lot of times these low-level crimes mushroom into bigger crimes. It is not uncommon for the police to go and the police are generally the heroes, they go to aid the mentally ill, but they go and go to the aid of somebody let’s say who is sleeping on private property, they try to nudge him, try to get him up, and that person lashes out at the cop because they are psychotic. Now this, what became a trespassing charge is now attacking an officer charge and the jail resources are used.
Howard Husock: Right. So that’s an example of why so many of the severely and mentally ill wind up in prison or otherwise behind bars. Stephen, in your article for City Journal, and remind us of the name of the article, would you?
Stephen Eide: Failure to thrive.
Howard Husock: Failure to thrive. And that’s a play on the Thrive New York, and again the book by DJ Jaffe is Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. Who is the publisher, DJ?
DJ Jaffe: Prometheus.
Howard Husock: Yeah. So pick that book up. But in you’re article, Failure to Thrive, you refer to the 21st Century Cures Act. Tell us what that is and how that relates to the discussion that we’ve been having?
Stephen Eide: Well the 21st Century Cures Act was one, is federal legislation, one of the last pieces, major legislation that President Obama signed into law before leaving office and it incorporated provisions from an earlier law that passed Congress called the Helping Families in Mental Health Crisis Act. And the kind of core of that bill was trying to refocus the federal government’s programs and efforts on mental health towards the seriously mentally ill. At the federal level there has been a long tendency of mission creep or mission drift to providing services to, you know, people with some variety of mental disorder but not the severely mentally ill. So, and this has been a particularly notorious problem at the SAMHSA agency.
Howard Husock: What does that stand for?
Stephen Eide: The Substance Abuse…
DJ Jaffe: The Substance Abuse and Mental Health Services Administration.
Stephen Eide: Yeah, within the Department of Health and Human Services. So, for example, the federal government is now providing funds to states for assisted outpatient treatment programs such as Kendra’s Law. New York has the most successful assisted outpatient treatment program in the nation because it has supported its program in a way that other states have not. And it is going to try to get more, it has created a new position of assistant secretary at SAMHSA in hopes that they will provide more effective oversight than has been the case in the past at SAMHSA.
Howard Husock: So, I hate to say this DJ, but this sounds hopeful. Are you hopeful about this as kind of an inflection point in a long history, in your view, of ignoring the most severely mentally ill?
DJ Jaffe: The difference now is that police and conservatives have taken this up. And I always tell people I am an uber Liberal, but Liberals and Democrats are not willing to address unpleasant truths like not everyone recovers. Some people do need hospitals. Some people with mental illness are violent, being psychotic is not a right to be protected, it is an illness to be treated, and things like that. So the optimism I see comes from places like Manhattan Institute who have done a stellar job on this issue and bring it to the public. The International Association of Chiefs of Police, the New York State Association of Chiefs of Police, the National Sheriffs’ Association, the mental health industry basically. There are two mental health systems. One is run by the industry which is serving those well enough to volunteer. All the others are being offloaded to criminal justice and they are starting to realize this has to stop and try to return care and treatment to the mental health system. Tim Murphy was a Republican, was lead on the health and family…
Howard Husock: He’s a congressman from Pennsylvania.
DJ Jaffe: …and he’s been, and also a psychologist, and he was on the lead of crafting this.
Howard Husock: Okay, so this has been another of our 10 Blocks Podcast series here at the Manhattan Institute. I should note that the plug for the Manhattan Institute from DJ Jaffe was unprompted by me…
DJ Jaffe: It’s true.
Howard Husock: …but we appreciate it. I have been joined by DJ Jaffe, author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, new on Prometheus Press.
DJ Jaffe: And that comment was solicited, your book for my book.