Stephen Eide and Rafael Mangual sit down for a hard-hitting conversation on homelessness, mental illness, and the policies shaping America’s cities. The discussion explores the breakdown of family support systems, the limits of government intervention, and the thorny questions surrounding institutionalization and public safety. Eide argues for a more realistic, balanced approach—one that confronts the realities of serious mental illness while pushing for practical, effective reforms.

Audio Transcript

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Rafael Mangual: Hello and welcome to another episode of the City Journal Podcast. I'm your host, Rafael Mangual, and I'm joined today by my colleague Stephen Eide. For those of you who don't know, Stephen Eide is a senior fellow at the Manhattan Institute. He's a contributing editor at City Journal and he is our leading voice on all things homelessness, mental illness, and the intersection of those things with urban policy and public safety. So I'm really looking forward to a fantastic conversation. Stephen, thank you so much. Welcome to the show.

Stephen Eide: Thanks for having me, Ralph.

Rafael Mangual: I'm always interested to hear people's stories. This series that we're doing called “Who We Are” is meant to kind of give people a sense of what work it is that sort of defines the Manhattan Institute and City Journal as institutions. But I've been starting a lot of these conversations, which is questions about how people got here because what we do is kind of interesting and weird and in some ways on the margins, and I think a lot of people are interested to know how it is that we ended up doing what we do. So maybe we can start there and you just talk a little bit about how it is that you ended up writing about public policy, ended up at a think tank. Is this something that you always wanted to do or was kind of a happy accident?

Stephen Eide: Yeah. Well, my background is political philosophy. We have people on staff who are PhD economists. We will have people like yourself who are lawyers. I went to graduate school to study political philosophy, the history of political thought, Plato, Locke, Rousseau. And so a lot of that has no direct connection to what I work on now. But one question that preoccupied me at that time was just mental health. And it struck me at that time that I could understand something really important about America and American norms if I understood why people decide some problem is a mental health problem as opposed to a moral problem, a problem of living. Is it okay to just call someone unhappy or is that a clinical thing? And I've always thought that that could just understand something really... It'd probably take me a long time to understand that in fullest implications, but I thought it would be a great way to see into American norms and values. I came to New York to work this job in 2012 and there immediately just..

Rafael Mangual: How'd you swing the job offer?

Stephen Eide: To get to? I got here the old fashioned way by applying online.

Rafael Mangual: Okay. What was it about MI that made you want to,

Stephen Eide: Well, so in between studying Straussian political philosophy at Boston College and coming here, I worked at a small think tank in Worcester, Massachusetts, but which, like MI, focused on urban policy. It was, like MI, a place where I found conservatives who cared about cities. So that was where I earned my spurs and started working on urban questions from a conservative perspective. And then if that's what you decide you want to do, MI is the big league naturally where you want to go. So it took a little while, but eventually an opportunity opened up and at that time I was not working directly on homelessness, mental health or even really what you would say, social policy questions. That was the Tea Party era. I was working on fiscal stuff, public pensions, cities going bankrupt. But you come to New York, like any ordinary New Yorker, you start noticing homelessness. What else is there to talk, talk about, right? Sometimes. And homelessness, I knew from an early period on it just seems to encapsulate government dysfunction, government failure. Nobody wants this, everybody agrees it shouldn't exist. Everybody has been saying it should exist for a long time by this point. It keeps existing. Why is it that government lets us down? Homelessness is a really sort of important way to sink your teeth into that question, really kind of concrete way to think about why government just doesn't work in such an obvious way.

Rafael Mangual: Yeah, no, I mean that's an interesting way to frame it, right? I think embedded in that question of why does government fail us on this front is the idea that there is something that government could do to make it better. And so I want to dig into that topic, homelessness, and I also want to talk about serious mental illness and the intersection of those two phenomenon, but I've always had a problem with the term homelessness because it implies that the way to frame the issue to frame what you're seeing on the street is a byproduct of a lack of home. When we say, well, this person's homeless, it gives someone the sense that, well, if you just gave them an apartment, all would be settled. And I think that's probably wrong in part because people don't just end up on the street for want of a home. The reason that they don't have a home likely has a lot to do with all these other reasons why they're not successful generally. And so what's your thought on that? I mean, there's this whole kind of world, I mean we're in New York City with a new Mayor Zohran Mamdani who sort of built his campaign around the idea that homelessness was a problem that could be solved by simply giving people housing. Is that right? Is that wrong? Why?

Stephen Eide: Yeah. Well, I wrote a book about homelessness a few years ago, and one of the main questions I tried to figure out in the writing of that book is where did this term come from? Because back in the sixties, people talked about poverty, people talked about all kinds of problems that we talk about now. They didn't use that term “homeless” in the way that we do now. And I was like, where did they come from? Why do people start talking about it? And the answer partly is there is a kind of new problem or new version of a problem that developed around when people started using that term around 1980. That is, but also I learned, and people were open in saying this, that there was a deliberate attempt by the activist community to use a new term. The previous terms had been “bum,” “vagrant,” terms that people nowadays look at a little kind of stigmatizing. We wanted to get away with that in the 1970s, but also we wanted to point people's attention to our activists’ preferred solution, namely more subsidized housing. So if you already define the problem as homelessness, you've already won an important victory. You're already on the way to convincing people that housing, subsidized housing is the policy solution to this period in ways that you alluded to that abstracts from a lot of other things involved in this issue. And so it is important that we kind of hold on to those instinctual difficulties that we have with this term. Like, well, I just rode the subway with some guy who, okay, I believe he probably doesn't have housing, but he also had some other things going on. What about those other problems? Some people will answer, listen, listen, listen, we will get to all those other problems later. You just focus on the fact that this guy doesn't have housing. Let's go in. That leads to that theory, housing first, which is something I spent a lot of times criticizing. And it's funny when people, coming from that experience of learning that homelessness was deliberately invented by the activist community, and I found examples of people basically saying that they did that, that now people are saying, actually “unhoused” is the correct term.

Rafael Mangual: The politically correct term.

Stephen Eide: “Homeless” is stigmatizing, “unhoused” is not stigmatizing. It's better. It's like, well, you guys just tell me what you want me to do. Right. “Homeless” was your idea to begin with.

Rafael Mangual: That's right. That's right. Yeah. I mean, it is interesting to me because when you ask people why it is that someone ends up on the street and they give you all sorts of reasons, poverty disenfranchisement, a lack of investment in the community, and they tend to start with reasons that are present in the lives of a lot more people than those who are living on the street. And that always stood out to me. I mean, the subset of the population experiencing poverty is a lot larger than the population living on the sidewalks or in the subway system. The subset of the population experiencing unemployment, joblessness, socioeconomic inequality of all kinds is much larger than the number of people that you'll see living on the subway or on a park bench. Why is it that someone who is experiencing all of those things isn't living on the street?

And my sense is that well, at the end of the day, they have family that they can fall back on, they can move back home like George Costanza moving back home with his parents once he's unemployed. I mean, he doesn't just go live on the sidewalk. Why is that? My sense is, well, he has things going for him. He's not crazy for one thing, he's not a burden on the people around him. And so they can step in and help in those times in which there's a lack of resources or a lack of opportunity, which then leads to another question, which is, well, what then is explaining why the people who are on the street don't have those other opportunities, don't have those things to fall back on, don't have willing family members to open up their living room or their couch to these individuals.

And so maybe that's a road we can go down because I think one of the things that, especially if you live in a city like New York that you tend to see kind of characterize the homeless population is almost invariably they are either drunk or high or in the process of getting drunk or high, or they are clearly mentally ill, right? They're having a full-blown conversation with someone who's not there. You can see that they're kind of detached from reality in some very visible and obvious way. What is your sense of that? I mean, why is it, or is that sense just wrong, that you don't really see kind of “normal” people living on the street?

Stephen Eide: Yeah, well, let's steel man this for just a second. I mean, there is this important housing component of the problem and the history is very useful in understanding this. We used to have a lot of bad housing in America, really low quality. It was crowded, it didn't have adequate plumbing, but it was very cheap. And very, very poor people, the poorest people in America could actually find some sort of housing to keep them out of. They didn't have to live on tents. They could live in some sort of housing provided by essentially for-profit landlords, just like you can find something to eat if you're really poor nowadays in big cities, you could find housing just as easily. Back at a certain point for various mostly regulatory reasons, we decided we want people to live like that, and all that housing went away, and so housing policy went from being about bad conditions, quality, to affordability, not coincidentally

Bad housing goes away. Also housing becomes much more unaffordable. So that goes on, but that intersects with the probably more important question you were talking about point you're making there, which is that people don't become homeless when they run out of housing. They become homeless when they run out of family and supports and all the other things that people would fall back on if they encountered unemployment or disadvantage. They have family who would take them in and keep them off the streets or out of a shelter. Why is it that some people lack that option, lack that social support, which when it snaps leads to them having to rely on government in some form? Well, some of those people are very hard to live with because they have addiction, because they have untreated serious mental illness. They came from a family. They had a family at one point who provided them housing, but maybe that family had young children that they were also caring for. Maybe that family had female relatives, maybe that family didn't like that this person was bringing around his no-good friends all the time, and maybe that person was stealing, was betraying, was violent. At a certain point that social support snaps and thus the housing, if it's going to exist at all, has to be provided through some sort of government fashion.

Maybe some people have said just sort of slightly more capacious housing. If you have housing that allows people to have more room, more distance between each other, not a scenario you're going to find as easily in dense New York City, but in other parts of the country, you mentioned poverty. So when I researched my book, Mississippi was the state with the highest poverty rate and the lowest homelessness rate. I've been in Mississippi. You drive around, you don't see a lot of homeless people, you see a lot of poverty and see a lot of just sort of ramshackle housing that maybe it's easier to keep the distance but keep people still housed. So the housing issue is not made up. It's very real, but it also intersects in these very important ways with these social behavioral questions that again, to the honest observer are right there on the face of things, but oftentimes in the debate get kind of submerged.

Rafael Mangual: Yeah, yeah. No, I mean when I think about the provision of housing, I think, one thing first always, which is that for that to work, the person has to be capable of living in that kind of setting. And part of the reason why I have that thought is I have some personal experience with this. I have a distant family member who was seriously mentally ill, used drugs, that sort of thing. And the city's answer to her problems was to give her a subsidized apartment in a really nice neighborhood and in a nice building. This was a place that a lot of people who were making a hundred thousand dollars a year would feel lucky to get to live, and yet she could live there for free. Despite that, this is a woman who up until she was eventually civilly committed in the last years of her life, would end up on the street constantly, would turn up in hospitals in different parts of the state, would be found on the street, would be missing for weeks at a time, not living in the housing that was provided. And the reason was that this was a person who was incapable of living alone and someone who had in a lot of ways alienated almost their entire family over years.

My frustration with the way that we have the policy conversation about homelessness is that not enough people seem to want to accept that reality that a lot of the people who are living on the sidewalks, in the subway cars, on park benches are just not capable of living in housing or unwilling to live in housing that's available to them. I mean, one of the things that I don't think people appreciate is in a city like New York, we have an abundance of homeless shelters. I mean, they are everywhere. And you talk to some people on the street, as I have, who are not completely visibly far gone, and I'll ask them every once in a while, why not go to a shelter? It's cold, it's raining. And they'll say, well, I can't bring my drugs into the shelter, or it's not really safe. I get robbed sometimes and I don't want to bring my stuff in. And you think about that, there's no way that you can be less safe than you are here in the subway car, but there are people who make that choice. I mean, what do we do about those problems?

Stephen Eide: Yeah. Well, being housed sounds like, and maybe people imagine it is just a passive experience, that it's something that happens to you. It doesn't come with any duties, any responsibilities, but the way that you're trying to talk about it is much more realistic, that all housing is shared in a way in that you have neighbors or you have maybe a landlord that you have to deal with. And you can just say, for example, we're going to give homeless people housing and we will never evict them from that housing because we don't want them to be homeless again. Well, but if that person behaves or does certain things that would normally merit eviction, that's going to create some other problem. Maybe they stay housed, but their neighbors are not going to like it. If they're relying on some sort of private landlord, he's going to be unhappy about it. It just leads to problems. If you think of housing as just, again, this is someone who just, he was a victim of circumstance. He wound up where he was based upon no fault of his own. If that's the way you think about these things, then when you move someone into housing, you might de-emphasize the need for kind of behavioral change that's going to be ultimately more important for him to live a better life and certainly for his community. And that absolutely gets lost in the debate. And to some extent, when you're just trying to create these kind of policy systems around these problems, which always involve some sort of abstraction from the way things look inside families as you're talking about, because the things that you're talking about are the things that absolutely families talk about all the time when they're trying to help their homeless relatives.

Rafael Mangual: Yeah. Yeah. No, I mean I think it really does kind of fall outside the scope of our policy conversation in an unfortunate way, this problem of how these individuals interact with the people in their lives that are supposed to love them, that they're supposed to be able to fall back on. I don't think that they really appreciate the degree to which everyone has a limit. And sometimes these people have problems that are just too big, and too big for them to handle in a family setting, too big for them to handle in their own homes. I mean, people could, because of their mental illness or their drug addictions, could have been abusive and push their children away or their significant others away. They become a burden. They're dangerous. They're untrustworthy because they steal, et cetera. But that then brings the question, well then who or what steps in the place of family? And the obvious answer to that question is the government in some way, but what does that look like? I mean, we started this conversation by noting that the government is pretty consistently failing, at least in cities like New York and San Francisco and Los Angeles, places I've been to where homelessness characterizes everyday life In those urban enclaves, what does a solution look like? Why do governments continue to get it so wrong?

Stephen Eide: Yeah. Well, yeah. When homelessness gets going and the early 1980s, what happens is certain types of problems that were kind of managed by for-profit sector or families, that breaks down for various reasons, often because of government interventions, but then government has to create these elaborate systems in response. And that's what we are now. We will have a public sector government funded solution to homelessness. What will it look like? That's what the debate is about. The first thing to think about is just what's the mix of law enforcement on the one hand versus social programs on the other? By social programs I mean health, human services and some sort of housing, some sort of residential program. What's the mix? Very extreme activist types will say, law enforcement just shouldn't be involved. Cops don't know what they're doing. Cops don't understand mental illness. Stop me if you've heard this one before.

We'll leave it to the experts. They're the ones who really get it. Cops, it's not just brutal, it's ineffective, and we will never fix the problem if law enforcement's involved. Now, most Americans do not accept that. And if you are a politician who comes in office and thinks that you can implement that, you are going to get burned very quickly because street homelessness is this 80-20 issue that the public's tolerance will wear thin and they're going to want something done about it. And then another way to think about why that mixture is, so health, human services, housing programs can help certain people, especially people who are motivated to use those programs. If you force those programs to take people who are too troubled for them, it's not going to work. And the people who could benefit from those programs will benefit less from those programs, and those programs’ integrity will just kind of break down. I mean, the mental health example is good here. So we have mental hospitals and mental hospitals are for people who meet the certain types of rigorous standard for commitment. If you say that we just shouldn't have mental hospital or we should minimize the number of people in mental hospitals, they should be in community mental health programs, okay, but that means those community mental health programs will find themselves in a position where they're not going to be able to help the people who they're really set up to help.

So we're trying to get the mix right, and it's very important to affirm the role that law enforcement type interventions have here. And it's also important to think through the type of values we want to respect when we're setting up those types of social program responses. How important do we think sobriety is? How important do we think employment is? And things like that. Or it's just the case that we just give people housing and let them take things from there?

Rafael Mangual: Yeah. I want to talk a little bit about the law enforcement aspect of this because there are people who are by virtue of their very serious problems, their mental illnesses, their addictions, the combination of those two things are going to have episodes that will require some kind of intervention because during those episodes, they become a serious danger to either themselves or the people around them. And we've seen this go wrong more times than we can count. You have Michelle Go getting shoved on to the subway tracks in front of a moving train. You've got people who hurt family members during a schizophrenic break because they're convinced that the CIA is hiding in the walls and no one believes them. And so they take a knife and hack people up. We’re having this conversation in mid-February where in the news, a deranged father gunned down his children and wife had a hockey game. I mean, there are going to be situations in which if we allow people to live in an unrestricted setting, that they're going to reach points at various times where intervention is necessary. And I think one of the most kind of hubristic ideas animating our policy debate right now is this idea that we can handle those situations without force, without a party that is authorized to, capable of, and trained in incapacitating, at least temporarily, individuals who don't want to be incapacitated, which is always going to require force.

Our mayor, Zohran Mamdani recently made some controversy because he asked the Queens DA not to prosecute an individual who was shot by police, survived, but that individual, the police were called to that house by the individual's parents because he was a danger to them in that moment. This is someone who clearly suffers from a serious mental illness. The parents became unable to control him. He was breaking things, he was being threatening. The police show up, the kid immediately grabs a knife, charges a police officer who does all the can to retreat and then eventually is forced to discharge his weapon. Is there any getting around that? I mean, what do you make of the people who say that we can just take police out of the equation, take enforcement out of the equation and handle this in some hands-off kind of way? Is that realistic? Strikes me that the answer is no?

Stephen Eide: Well, yeah, I don't think so. And when you're talking about police calls for service, yes, you are talking about a crisis situation and you are talking about a desire that someone who placed that call to restore a modicum of order. Okay? So yes, they're not asking for everything in their lives to be fixed for the rest of their lives. They want to restore a modicum of order. So there is something imperfect about what sort of solution you're going to apply in that situation. Okay, fine, but how did we get here? How did this crisis situation arise? Nearly always, it's because of some failure on the part of non-police systems. So police are in this situation because these other service systems, which these people who are involved in this situation had some contact with. Normally, it's not like they've never had any contact with the social services, with mental health, whatever. They've had some contact, especially in a place like New York, where, New York is really service rich as opposed to rural areas. But for whatever reason, that didn't work out for these people. So making services available to them, trying to persuade them, voluntary interventions, it didn't work. And then things get worse. And then ultimately, yes, coercion has to be part of the mix. That's what it looks like to me.

I mean when we talk about how the deinstitutionalization of the mentally ill really wound up with the trans-institutionalization of the mental, you have this large population correctional institutions that would've been in a mental institution, had history been different. How did that happen? Well, it didn't happen because you took the people from the mental asylum and put them in the other correctional places. It happened because you let them out. You developed some sort of community system, you hope that the community systems would work. It didn't work out as much as people thought it was going to work out. And as a result, this correctional law and order type solution had to intervene. So that's the way things normally play out. So the idea that we just never tried that before, and that we've just been doing all-in law, nothing but cops, courts and corrections, and why don't we give the social services a try? I don't know what you're talking about. It's not just slightly how it works.

Rafael Mangual: Right? It's almost like those people who insist that real socialism has never been tried before. It's like they continue to insist that they have the answer to what is proven to be an intractable problem that is plagued societies throughout human history and in every geographical corner of the world in which humans have lived. And so it strikes me as very unlikely that we're going to find some unique solution to this problem that we haven't tried before in all of these years. I want to talk a little bit about institutionalization because just going back to that recent police shooting here in New York City, this is an individual that was living at home and clearly unwell, which means that the parents were obviously, where in, I want to be very clear, I'm not laying blame on anyone here, but I do think it's an interesting question. Why is it that someone who was that unwell is at home and not in a place that's more restrictive, that's more secure, where they can make sure that there is compliance with their medications and that sort of thing? And I suspect a part of the answer is an unwillingness to do that on the part of the family. And correct me if I'm wrong, but the sort of most direct or easiest way to get somebody institutionalized in New York City and most other parts of the country is for that process to involve the immediate family of the individual. I mean, there are few other people who can competently testify to get that person civilly committed. And so I always bring the question, which is part of the case for a bigger role for the government to play in committing people who are severely mentally ill and incapable of living in society is part of the reason why the government should play a bigger role if they should, that in some cases families just don't have it in them to pull that lever until it's too late.

Stephen Eide: Well, this question of civil commitment of the mentally ill is this interesting case where you went from a big government solution in the old asylum era to a family solution in the modern era. Normally, like most social questions, it's the opposite. The family was robust. Now the family's weak because government's everywhere. But back in the day, there was more deference given to, there was just this understanding that this is not a problem families can handle. Okay, you have a 21-year-old son with schizophrenia. We are not going to ask you to handle that. You're working class, whatever. You can't deal with that. That's the government's job. Nowadays it's completely reversed. You have a 21-year-old schizophrenic son. What am I supposed to do about that? Well, we would like you to keep him with you. We are going to provide you with these various community sources. We're going to sign him up for Medicaid and stuff and make stuff available to him. But you're probably going to have to be around and access to an inpatient psychiatric hospital is going to be difficult for you. Under extreme cases, you're going to be able to do it, but that's something we are deemphasizing. Mostly it's you. The community-based system is the family-based system. So what we ask, we ask a lot of families and it's a really very unpleasant existence. Whether families are reluctant to initiate, overly reluctant to initiate the commitment process, I'm not sure. I mean, generally speaking, I would say that family groups would like a little bit more access for the most part. Sometimes advocates can get to them. Sometimes they're told something about how everybody recovers and they can get their heads turned around a little bit. But certainly the family-based system could work better than it does. We are going to have a community-based system. We are not going to bring back the old asylums. That's just not realistic. No country has ever done that. We could do more to support families and one thing that that would require is a little bit more easy access to institutionalization on a few weeks basis or few months basis or something just to stabilize someone. Otherwise the type of incidents that you're referring to will just keep recurring.

Rafael Mangual: Yeah, I mean one of the reasons I think that the anti-law enforcement side of the debate gets so much traction is that for better or worse, there is openness on the side of rank and file law enforcement officers to doing less in this space because it's so unpleasant and because I think a lot of them feel like they are set up to fail. I mean, I speak to cops in New York City and in cities across the country all the time, and when I ask them about mental health and their interactions with the mentally ill population, one of the things that they always roll their eyes and tell me about is that they really wish they would stop getting the calls because they're often incredibly contentious. They have a higher risk of use of force, of injury to the officer and to the person that they're trying to subdue. And all of that work will lead to little more than a 24-hour stay in the hospital before the individual is back out on the street. I mean, you mentioned that the ideal is a few weeks, maybe a few months, to truly stabilize someone. I mean, talk a little bit about how different that is from the sort of normal interaction when someone who is suffering from severe mental illness comes into contact with law enforcement. What does that normally look like?

Stephen Eide: Well, yeah, as you allude to there's this rinse and repeat experience, frequent flyers or whatever. I mean, it really irritates me when people say that law enforcement don't know anything about mental health. If there's anything to the idea of lived experience or lived expertise, you can't help but learn about the nature of mental illness. And by the way, a lot of people who work as a mental health professional have no contact with violent schizophrenic people. They don't know anything about that. All their knowledge is from a textbook. So there's this idea we need to bring in social workers, mental health professionals to the academy to teach deescalation training. My idea has always been let's bring the cops to the social work programs to tell people what acute psychosis really looks like because don’t assume that they're going to learn that in any other way. But yes, when people who are big advocates of social worker response, crisis response programs say that cops don't really want to be doing this. There's something to that. Cops envisioned different type of work. When they look back on a long career, that's not what they want to be thinking that they were doing for two decades. But partly because there's no real solution. You participate in the commitment of somebody. He goes to hospital, he stays there for 72 hours, he gets just stabilized enough. He no longer meets commitment criteria. Back on the street. Treated and streeted.

Rafael Mangual: Talk to me about that. That seems to be kind of circular, right? There's this idea that, well, you need to meet a certain standard in order to be eligible for commitment. We bring these people in a state of absolute crisis. We drug them up to the point that they're kind of staying still and are somewhat okay in that moment. And then we say, well, in this moment we can't commit them because they're stable. And then we just put them right back into the same environment in which they failed. I mean, that seems to me to be backward. Why can't we look back on the history and say, well, hey, this is the fourth time this person's been to this hospital in the last six months. Clearly, when we think they're stable, they're not stable. And so why don't we throw that short-term stability out the window in terms of our analysis of whether or not that person should be committed?

Stephen Eide: Well, right. I mean, it's very parallel to the dangerousness question and the bail debate have everyone who knows anything about this person, he has been working with life person for a long time knows if you do this, he's going to fail because he failed every other time he did it. So if we're talking about doing it again, we're going to fail. Shouldn't social policy be about prevention? Not reaction, but prevention. We are setting ourselves up to be reacting again. Why are we doing this again? Look, one of the reasons, so there's the question of the legal standard. There's also the financial question of just bed capacity. A lot of people inside these systems, they're trying to just keep this flow going because if you have somebody who's just stabilized just enough and they're occupying a bed that maybe somebody needs more because they're even more florid. So that happens, and it happens to be the case that psychiatric hospitalization is a very expensive form of healthcare for various ways. Systems are under pressure to reduce those costs. We don't have as many psychiatric beds as we need. There's a fairly broad consensus that that's true. And so if we just had more beds, even if we didn't change the law, maybe we would find that people could be kept stable a little bit longer, at least on the inside than they are now where there's just this flow constantly.

Rafael Mangual: I have a couple of things I want to dig into that you brought up there, but before I hit that stuff, I want to talk a little bit more about those kind of interactions. When someone does get brought to the hospital against their will, so they are given medication, they are temporarily stabilized just enough that they no longer meet the commitment standard. And I think we agree that it's a problem that we can't take into consideration the broader prior history when making that kind of determination as opposed to just sort of confining the analysis to that immediate window that the individual is in. But my understanding is that part of the problem too, on the capacity side is that the sort of professionals that are handling these individuals wouldn't qualify to trigger the commitment inquiry. Is that right? Like a nurse practitioner versus a psychiatrist for example? I mean, is it the case that every single person who ends up at Bellevue for a 24 hour period is getting seen and evaluated by somebody with who is considered competent under the law to have that person committed or to trigger that, initiate that process?

Stephen Eide: I don't know if to what degree that is a big policy problem, I guess I'm not sure. I'm not sure.

Rafael Mangual: That's fair enough.

Stephen Eide: Go ahead.

Rafael Mangual: Yeah, you mentioned, which I think is a really good analogy, the bail analogy. We have these individuals who have these very lengthy criminal histories. They come back to court after failing yet again with a new charge. And in New York, we tell judges that under no circumstances are you to consider the risk that this person poses to the public when making a decision about whether and under what circumstances to release the individual. And when people ask people, why on earth would anyone adopt a policy that's so crazy on its face? I mean, I try to do my best to give them the other side of the argument, which is that there is a great deal of discomfort, particularly on the American left with making a particular type of error. There are kind of two category errors that you can make in the criminal justice system. You can accidentally confine somebody who doesn't need to be confined or you can accidentally release somebody who needs to be confined. Both have problems associated with them. And I think one of the things that sort of differentiates left from right in that particular debate is that people on the right are more concerned with the risk to the public of failing to incapacitate somebody who should be incapacitated than they are with accidentally confining somebody who could have done ok on the outside. I think that's probably the same deal here in the mental health context.

Stephen Eide: But there is, and I don't know if this is where you're going, there is a kind of libertarian perspective, which is like you're trusting government with an awesome power to deprive people of their liberty who have not committed a crime. You're confining them and they're not guilty with anything. They're not even charged with anything. Well, maybe they were guilty of something a long time ago, but at the moment you're just confining them because they're sick. And there's a libertarian strain that, and it does come down to trusting the government, which is something that broadly speaking in American society, we seem to have a lot of trouble doing. So you do have to kind of own that to some degree if you were trying to make the argument that we need more beds and we need more commitment for sure.

Rafael Mangual: And I think part of the reason why it's harder to make that argument or convince people is that you have this history, which I want to talk a little bit about because the deinstitutionalization movement didn't come out of nowhere. I mean, we've talked about it in passing, kind of taking it for granted, but I think part of the reason that it happened was that there were abuses in the system. The government failed in a pretty spectacular way, and that eroded the trust that I think is necessary for people to concede that the government should have that very awesome power as you described it.

Stephen Eide: Yeah, there was a much more casual attitude taken towards commitment. And at that time, there was a much less active and empowered public defender bar on the scene at that time. And there was this kind of dumping ground dynamic. And sometimes this happens, and in a way it's kind of unavoidable in America, where the asylums were made responsible for all kinds of just cases that people didn't know what else to do with. They had a very large population of just old, senile people, who didn't have some sort of public nursing home to go to. Just put them in the asylum with the 21-year-old schizophrenic people. And so all in the population just got bigger and bigger and bigger. And people knew it was a problem for a long time. And they were in the situation where they were very, very expensive programs. Something like a third of the state budget of New York went to its mental asylums. That's a big expense. And it was going towards a program that most people regarded as unsuccessful. It was.. So it's already failing. Do you dump more money into it?

Rafael Mangual: Unsuccessful In what way?

Stephen Eide: It wasn't making people better. The population just keeps growing.

Rafael Mangual: Do you make people better? Is that something we know how to do?

Stephen Eide: Yes. I mean, if you take for example schizophrenia, it is certainly realistic that, okay, so let's take a good case. Okay, you have somebody who has a family in the picture. Most importantly, he has somebody in his family who is willing to be his advocate to navigate the system, figure out what's there, what can help him, and who is going to stay on him about, for example, taking his medication. If you take psychiatric medication and you have schizophrenia, it will tamp down your symptoms. It won't cure you, but it will tamp down the delusions and make you easier to live with and just more manageable. Your life is not going to be the same. Their parents' expectations for you when you are a little kid are not going to be fulfilled, but you will not necessarily wind up in jail or on the streets. It's not a perfect medication regimen. It's not a perfect community mental health system. But certainly it can work and it does work for many people. It's hard to predict in advance for, and there are lots of people who don't come from impoverished backgrounds who wound up things breaking down in their families. And those are really, really sad cases, but it's not futile. And we do have to kind of, I think in our role affirm that. We have to affirm that treatment works and not bad mouth psychiatrists, not bad mouth psychiatric medication. No. That's just a bunch of side effects. I understand why people don't want to take it. No, we do have to be kind, understand our role here and defend treatment and defend the potential of a treatment.

Rafael Mangual: See, that strikes me as an interesting sort of difference between the sort of traditional criminal justice debates and debates about institutionalization. Because I mean, my position in the criminal justice policy debate is that really we don't know how to reliably rehabilitate persistent criminal offenders and therefore incapacitation is kind of the best that we can hope for. And then general deterrence on the margins for people who haven't quite yet gone over the edge into a life of crime is sort of the second best thing we can hope for. But rehabilitation is largely a pipe dream. Now does that mean that there aren't going to be one-off cases? No. Does that mean that there might not be some intervention as yet discovered that can in the future be reliably deployed to get people onto a better path and keep them there? I think that's very much a possibility that we should continue to explore and invest in. But as of right now, when I see somebody who's got 20, 30 prior arrests and multiple prior convictions, it's like there's no reason to expect that there is any intervention that is going to get this person to obey the law into the foreseeable future. And so let's lock them up for as long as we possibly can. But that's not really the case in this space. There is more hope.

Stephen Eide: Well, I know what you're saying, and I guess I would respond in two ways. So first of all, even within the incarceration basket, you'll find a lot of correctional officers who are at least interested in trying rehabilitation if for no other reason that people got to, they need something to do. But they also really believe, and I have been able to visit jail programs, which can be hard to get into because

Rafael Mangual: You and I have both visited Rikers Island together.

Stephen Eide: And one thing that happens there is you have these correctional professionals, not medical professionals who are proud of their program. We are doing something differently. We're really trying to help people. I understand that a lot can unravel once somebody hits the streets and they get out of here, but we are going to try. So in a way, it is coming from those disciplines to try to thread something like rehabilitation inside incarceration. But the second and larger point I would make about this that really informs my research and trying to look at that social program side of this picture while you and your colleagues focus intensely on the law enforcement, incapacitation, lock them up side of things, is we're going to have a welfare state in America. We are going to continue to spend lots of money on healthcare, on social services, on housing. It's just not going to go away. The public doesn't want it to go away. What kind of mixture of health, human services, housing programs do we want? And so it's important that we engage in that and make sure that we get those programs aligned with our values as opposed to just saying that it's just all a matter of failure indifferently.

Rafael Mangual: No, I think that's an important point and something that often gets forgotten, which is one of the reasons why I think the right is so easily dismissed as the cold, unfeeling side of these debates when in reality, I don't think that's true. Certainly not of you and your colleagues who work on this issue, certainly not even of me, despite my willingness to lock somebody up for a really long time. I mean, that's coming from a place of compassion, believe it or not necessarily for the offender, but for their potential victims.

But I do want to just dig in a little bit more before we end on this question of what works. One of the things you mentioned earlier was this idea of deescalation training. And this is something that comes up in both of our worlds. I mean, there's this idea that police wouldn't use force so much if they were just trained in this sort of magical deescalation. There's this sort of incantation that they can recite, and suddenly someone will calm down and they will stop resisting and they will willingly give up their hands for the handcuffs. And I think that's largely fantastical thinking. And when I was writing my book, I dug into the literature on this quite a bit, and my sense of it was that generally deescalation training doesn't work very well. It's not reliably something that you can deploy in the field with a high rate of success. It's relatively unpredictable both in the law enforcement setting, but also in the mental health institution setting. I mean, from what I remember, the mental health wards that were kind of restraint wards where individuals who were resisting were kind of put in straitjackets or hand restraints, and you get the five big guys in the white coats to hold you down versus deescalation wards where the injury rates both to patients and to staff were significantly higher. And incidents of non-compliance were higher. And I think that's also what you see in the law enforcement field. What is your sense of deescalation? Is that something that we can kind of dismiss as ineffective? Am I wrong? Is it something that works all the time or is the truth somewhere in between?

Stephen Eide: Well, first of all, I think it makes sense to think of deescalation more as a disposition than a training or skill. When government officials speak about this, it's like it's something that you give somebody like knowing how to do algebra or something, whereas in a more meaningful way, it's just slowing down and being patient and being aware that especially if you were being videotaped, if you do the first thing that comes to your mind, you might regret it. So just slowing things down inn our world, you're probably going to need to do. And some cops, I think just naturally come to that conclusion anyway, especially if they've been through these situations before and they understand you just need to keep your head about you. That will just sort of look like deescalation something regardless of, and as we alluded to before, experience more than training is probably just going to be a better educator, but it will lead towards something that looks like deescalation.

Another thing that could be said on behalf of deescalation in the way that it's implemented is, so the alternative is replacing cops. So either you sort of train cops or kind of organize police resources in a way that you send certain types of cops who like this stuff to certain types of calls versus other cops who just have a different role to play. So that could be a way to prevent the more radical idea of saying that, no, we just don't want cops involved at all, which is, I don't think we have time to discuss that topic right now, but deescalation is like your grandfather's idea of police reform from the 2010s. Whereas now people decided, oh, we're not doing that anymore. We don't want reform. We want to abolish stuff. So there's value in defending it for that reason. But if you're going to do it, whether inside a mental hospital or inside a police department on calls, you need to be very robustly staffed. You cannot defund the police, or you need very robust staffing. You need to spend lots of money on mental hospitals, which Americans don't want to do because they think they're going to revive the asylums because you just need lots of bodies. And if they're not strong bodies but need to just restrict people's movement, then you need more people. And so those types of trade-offs, I think are not often not reckoned up to. It definitely is an over-hyped idea, but it may be preferable to some other alternatives coming down the pike.

Rafael Mangual: Yeah, no, I think that's right. I think part of my frustration with the emphasis on deescalation is that too often people assume that it's even appropriate in so many of the contexts in which things go wrong in which police end up using deadly force. And the examples that I often cite, I mean, there's no real opportunity for deescalation. I mean by the time that the police officers are getting there, things have deteriorated past the point at which they can be deescalated. I mean, the most recent shooting is a perfect example of that, right? I mean, the police are called to this home in Queens, the mother opens the door. There's a very cordial interaction between her and the first officer through the door. She invites him into the home. He takes basically one step over the threshold where the subject sees him and just grabs a knife immediately, and the officer literally doesn't even have a chance to get a word out and immediately retreats. There’s no…

Stephen Eide: And people always saying, well, cops provoke it. Cops escalate things just by their presence. And I know. Yeah. I mean…

Rafael Mangual: What do you make of that? Right?

Stephen Eide: So another problem I think with the deescalation case and the social worker crisis response case is like, is this really what the public wants? Is this the consumer demand thing? Look, when you're calling for a cop and a social worker comes like, wait a minute, I thought this was a democracy. When you're calling for a cop, you have a disorderly situation. You want a modicum of order restored to it. That's why I wanted you here. I didn't call you to just hang out for two, three hours until everybody's sure everyone has just calmed down and worked it out of their system. So to what extent is that what the community wants versus just like we want something just… We understand everything's not going to get better, but for now, things to get a little bit more orderly when you show up.

Rafael Mangual: Right? I don't want everything in the house to be broken. Let's save some dishes for dinner.

Stephen Eide: That's what the public is expecting,

Rafael Mangual: Right?

Stephen Eide: Even if they know mental illness is involved, let's triage this, okay, let's just get it under control for the moment. And maybe certain views of deescalation cut against that for sure.

Rafael Mangual: This is a fascinating conversation that I think we could probably have for the next three hours and feel like it's only been five minutes, but I want to close with just giving you an opportunity to give our new mayor here in New York City some advice. This is someone who seems to have very bold and in my opinion, ideas that lack any real humility for a topic that's incredibly complex. What advice would you offer him given what you know about his policy proposals and program?

Stephen Eide: Well, I'm interested in to the extent to which socialism will be able to grow. We'll be able to persuade people beyond its very narrow circles now that it's a good idea that it can work in America and what would be required for that. And you need to be able to show people that you can do functional government under a socialist regime. I think there have been a number of missteps so far. I think the property tax thing is going to be a misstep. That's not what people voted for.

Rafael Mangual: The property tax thing is referring to a proposal to significantly hike property taxes here in New York City to close the budget gap.

Stephen Eide: But on homelessness and untreated serious mental illness. And we come back to where we started. That is just such a vivid example into the ordinary New Yorker that government doesn't work. It leads to cynicism, and ultimately it leads to a desire for change, for a new administration. And if you can't handle that, or if people perceive it's getting worse and similar to crime, even if you insist that the number’s lower on your side, if they see it's getting worse, that's your problem. Okay.

Rafael Mangual: Yeah.

Stephen Eide: So he's already backtrack a little bit on the encampment thing before he said, I'm not going to dismantle encampments, even with the public wants it. Now he's saying he will. Good idea. But mental illness, I mean, look, is whatever else we disagree on about what government should do. Everybody agrees that government should be involved in addressing untreated serious mental illness. If you just take this very, very soft handed approach, if you assume that, just leave it to the professionals and they'll be able to persuade people to come in. There's a long record with that, and I think ultimately people are going to have doubts about your overall agenda, the things that are more important to you. If you can't maintain both adequate level of public order and credibility that you're trying to do something about the crisis of untreated serious mental illness, if they think that you're just ignoring it, then you don't want to have the reputation as a socialist who doesn't care about the mentally ill. That's really going to undermine your bigger agenda in what you're going to try to do.

Rafael Mangual: I think that's right. Well, thank you so much, Stephen, for a fascinating conversation. I hope you all enjoyed it. Please do not forget to like, comment, subscribe, ring the bell, do all the things for the algorithm so that we can keep having these really awesome conversations and sharing them with you. Until next time, you've been watching the City Journal Podcast and we will see you next week.

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