New York City mandates psychiatric care for the homeless

New York City will begin hospitalizing homeless people struggling with serious mental disorders, Mayor Eric Adams announced last week. He aims to get more individuals experiencing severe mental illness off city thoroughfares and subways and into treatment. Outreach workers, city-operated hospitals, and first responders may provide involuntary care to homeless individuals if severe mental illness endangers their well-being by preventing them from meeting basic needs.

Adams called the measure compassionate. He argued the city has a “moral mandate” to do more for homeless individuals who are struggling with severe mental illness, unable to recognize their needs, and incapable of seeking life-saving help.

“It is not acceptable for us to see someone who clearly needs help and walk past them. … We will not fail to deliver for our most vulnerable,” he said.

The announcement received immediate backlash from homeless advocacy groups. Adams has “continually scapegoated homeless people and others with mental illness as violent,” policy director Jacquelyn Simone said in a statement for the Coalition for the Homeless. She argued the city should expand access to voluntary mental health care and provide affordable housing rather than involuntarily transport people to hospitals. Donna Lieberman, executive director of the New York Civil Liberties Union,  accused the mayor of “playing fast and loose with the legal rights of New Yorkers.”

Other homeless experts and ministry leaders take a different perspective. Abandoning those incapable of recognizing their own need isn’t compassion, they argue. But Adams’ plan is only a part of an approach that should keep God-given human dignity front and center.

Of the over 580,000 homeless people across the United States, an estimated 25 percent struggle with serious mental illness. Over 75 percent suffer from mental illness, substance abuse disorders, or physical disabilities.

Somewhere between 50 and 70 percent of people struggling with homelessness and mental illness also suffer from a deficit of self-awareness, said Michele Steeb, a senior fellow with the Texas Public Policy Foundation.

For 13 years, Steeb directed Saint John’s, a program for homeless women and children in Sacramento, Calif. She estimates that about 70 percent of the women she worked with struggled with mental illness and addiction, and many didn’t realize it when they entered the program. Few suffered from life-threatening disorders. But for those who do, Steeb believes that procedures like Adams’ are critical.

Public mental health systems must be designed to care for people who not only have a serious mental illness but also refuse to seek treatment, said Stephen Eide, a senior fellow with the Manhattan Institute. As deinstitutionalization gained popularity in the 1950s and ’60s, the number of psychiatric hospital beds dropped. Between 2005 and 2010, available psychiatric beds fell by 14 percent. Fewer psychiatric beds meant more people ended up in jail or on the street, Eide said.

“Advocates like the idea of cutting psychiatric beds,” Eide said, “but … the number of seriously mentally ill homeless has grown as fewer people have been committed to hospitals. So at what point do we rethink that?”

Strict standards for committing an individual with a mental disorder to a psychiatric hospital accompanied this trend. According to New York law, a person may only be involuntarily admitted if treatment “is essential to his/her welfare, the person’s judgment is too impaired for him/her to understand the need for such care, … and the person poses a substantial threat of harm to self or others.”

Adams’ directive takes a proactive approach to this law, Eide said, by mandating care for those whose inability to meet their basic needs—not just an overt act of violence—poses a danger to themselves.

“For too long, there has been a gray area where policy, law, and accountability has been unclear, and this has allowed people in desperate need to slip through the cracks,” Adams said in his announcement.

The California legislature passed a similar bill earlier this year. In response to the state’s rapidly escalating homelessness crisis, Gov. Gavin Newsom proposed the Community Assistance Recovery and Empowerment (CARE) Court bill. The CARE Court program compels homeless individuals struggling with severe psychotic disorders—such as untreated schizophrenia—to complete a one-year care plan. Family members, charity workers, first responders, and other concerned parties can ask a county court to order a clinical evaluation of the individual severely affected by the psychotic disorder.

Opponents raised similar concerns about the program, which will begin next year. “CARE Court promotes a system of involuntary coerced treatment,” Human Rights Watch said in a statement. “The bill creates a new pathway for government officials and family members to place people under state control and take away their autonomy and liberty.”

A daily witness to the ever-growing homeless crisis on the streets of Los Angeles, Rev. Andy Bales strongly disagrees. Bales has spent the last 36 years serving the homeless, and 18 of those heading the Union Rescue Mission in LA. He supported the CARE Court Act and believes Adams’ directive in New York City is another step in the right direction.

Over 69,000 people are homeless in L.A. County, according to the Greater Los Angeles Homeless Count in September. Nearly 40 percent reported serious mental illness or addiction. More homeless people die from hypothermia in sunny Los Angeles than in New York. In 2021, 14 homeless people froze to death in LA.

“It’s absolutely not compassionate to let someone continue to suffer, even to the point of death,” said Bales. “When the trauma of the streets reaches the point of someone being a danger to themselves or others, I think we’re required by our Creator to intervene.”

Back in New York, Bowery Mission has served New York City’s homeless for 150 years. Homeless guests who visit their emergency shelter can shower, change into clean clothing, and spend the night in a freshly made bed. The ministry reserves about half of its 250 beds for clients in its residential and community programs. If a person’s mental health condition destabilizes their community, they refer them to services outside the mission.

President and CEO James Winans says that sometimes intervention is compassionate. Though he agrees with Adams’ approach, he understands the concerns of the measure’s opponents and the danger of acting rashly without protecting the dignity of the individual.

“All of that really goes back to seeing each and every individual as a person created in God’s image, who deserves to be treated with all the dignity and, frankly, individuality that God has created,” he said.

Both Winans and Bales are concerned about the program’s execution. California doesn’t have enough mental health workers, and New York also struggles to recruit and retain a strong mental health workforce weakened by COVID-19.

The directive isn’t a cure-all. “It’s one part of a bigger puzzle,” said Winans. An individual won’t stay in a hospital forever. What happens when they leave? He wants Bowery Mission and places like it to be one of the next stops—a community that will surround an individual as they pick up the pieces. “It’s going to take some investments across the board,” said Winans, “and … not public dollars, necessarily.”

An anomaly among most New York City charities, Bowery Mission doesn’t take government money. Winans believes this allows the mission to tailor its approach to build long-term relationships and share the gospel rather than only filling immediate material needs.

“It’s a misnomer to say we will solve homelessness. … There’s not just one type of homelessness,” he said. No one walks into a hospital and asks how they will solve illness, Winans pointed out. Doctors evaluate each person as a unique case. They start by asking questions.

Only 1 in 5 clients graduates from Winans’ residential programs. It takes a few times for most. “We have a very specific measurement of what flourishing looks like,” he said. Successful graduates have been introduced to Christ and overcome addictions. They are connected to the community and have stable income and housing, “utterly transformed,” he said.