Will New York Force More Mentally Ill People Into Treatment?

It is a nightmare that plays out on the streets and subways every few months: A homeless person with a history of mental illness or violence falls through the cracks or wanders away from the system intended to help him, surfaces in a psychotic rage and attacks a random New Yorker.

Though they make up a tiny fraction of crimes, the unpredictable attacks feed perceptions that the city is unsafe and stir demands for action. Politicians send police officers and National Guard members into the subways and pour money into outreach efforts and housing.

And as long-running arguments persist over how to balance public safety and the civil rights of mentally ill people, another outburst inevitably happens.

The debate resurfaced last month when Gov. Kathy Hochul proposed a package of laws to make it easier to take people in psychiatric crisis to a hospital involuntarily, easier to hold them there and harder for hospitals to push them back to the street before they fully stabilize.

But Ms. Hochul’s efforts, unveiled in her latest executive budget, face an uphill battle in the Legislature and opposition from progressives and civil liberties groups.

“Critics will say this criminalizes poverty or homelessness,” Ms. Hochul said last month. “I say that is flat-out wrong.”

She added, “This is about having the humanity and the compassion to help people incapable of helping themselves, fellow human beings who are suffering from mental illness that is literally putting their lives and the lives of others in danger.”

In proposing the changes — most of them longstanding requests from Mayor Eric Adams — Ms. Hochul joined a long line of leaders who have struggled to help people in psychosis on the streets and subways.

But even if all her changes were enacted, some supporters question how much impact they would have.

“We have to deal with the mental health crisis,” Carl E. Heastie, the Assembly speaker, said last month. “But this is another one where I always say to you: The hell is in the details.”

Ms. Hochul’s proposals include these changes to the state’s Mental Hygiene Law:

• Clarifying the threshold: Allow authorities to take someone involuntarily to a hospital for evaluation when mental illness leaves them so incapable of providing for “essential needs” like shelter, food or clothing that it causes a substantial risk of physical harm. Current law is less specific, though it allows involuntary transport to a hospital when someone’s conduct endangers themselves or others.

• Holistic decision-making: Require hospitals to consider psychiatric patients’ whole history, rather than just how they are behaving in the moment, when deciding whether to admit them against their will and whether to discharge them.

• Hospital admissions: At hospitals, give psychiatric nurse practitioners the power to admit patients involuntarily if a physician concurs. This would address a shortage of psychiatrists, though it only applies to 60-day admissions, which are longer than most.

• Mandated outpatient treatment: Make it easier to renew expired “Kendra’s Law” court orders, which require some psychiatric patients to get outpatient treatment after they have been discharged, including taking medication. Often, after an order expires, the person stops taking medication and their mental health declines.

• Improved coordination: Require hospitals to consult and coordinate with a psychiatric patient’s care providers in the community when the person is admitted or discharged, to keep track of patients after they leave the hospital.

The legislators running the committees with oversight of these issues have expressed deep skepticism about Ms. Hochul’s proposals. They have questioned the need for the changes and said they would force homeless people off the streets without giving them enough services. And they worry that not enough is being invested in street-level mental health workers.

State Senator Samra Brouk, chairwoman of the Mental Health Committee, acknowledged that the state’s “current crisis response is inadequate, and individuals suffering on the streets need our help.” But she asserted that expanding involuntary commitment “is not the compassionate way to get people the help they need.”

She vowed to oppose efforts that “coerce individuals into treatment or detention.”

Ms. Brouk’s Assembly counterpart, Jo Anne Simon, said politics and perceived dangers on the subway were driving the debate, not what was best for vulnerable people living with mental illness.

“My concern is we are not really addressing the problem, and we are potentially being asked to do something that I see as likely to exacerbate the problem,” she said.

But a psychiatrist at a nonprofit that provides social services and housing to people with serious mental illness in New York City said Ms. Hochul’s proposal could make a difference on the street.

The psychiatrist, Ellen Tabor, associate chief medical officer at the Institute for Community Living, said that if the “essential needs” standard for taking someone involuntarily to a hospital was widely used, a lot more people would get needed psychiatric help.

“To have the police pick you up and take you against your will, that’s terrifying, I get that,” she said. “But too often they don’t, and there’s a dangerous situation.”

Democrats control both legislative chambers and will haggle with Ms. Hochul about her proposals in negotiations over the entire budget.

Earlier this month, a coalition of 39 social service, housing advocacy and civil rights organizations sent a letter to Mr. Heastie and State Senator Andrea Stewart-Cousins, the majority leader, asking them to reject Ms. Hochul’s proposals and instead “invest in solutions that work, including housing, services and care.”

Since taking office, Ms. Hochul has poured about $1 billion into building out the state’s mental health system, including funding for new housing units designed for people with mental illness. This year’s proposals are smaller but do include some money for more mental health outreach teams and beds in inpatient facilities.

Beth Haroules, a senior staff attorney at the New York Civil Liberties Union, which signed the letter, said law enforcement and government should focus more on using the laws already on the books to reach people who cannot help themselves.

The language about who would qualify for involuntary transport to a hospital for assessment is too broad, she said, adding that Ms. Hochul’s measures would infringe on homeless people’s rights and leave them at the mercy of law enforcement officers who are not properly trained.

“It is that loss of liberty as a result of mistaken assessment by a law enforcement officer who is not clinically trained to make the determinations,” she said, “which deprives a person of liberty.”

Last year, people were involuntarily taken to hospitals for psychiatric evaluation at least 800 times from the transit system and at least 700 times from other public spaces, according to the mayor’s office, which only just started tracking the holds.

Ms. Hochul’s proposals do not include all the changes Mr. Adams has pushed for. One left on the cutting-room floor would require hospitals to seek Kendra’s Law orders for all psychiatric patients who meet the standard for them.

Brian Stettin, Mr. Adams’s senior adviser for severe mental illness, applauded Ms. Hochul’s advocacy and committed to working with her and state lawmakers.

“We are pleased that Governor Hochul is supporting measures to help people reclaim their lives, even when they cannot recognize their own need for assistance,” he said in a statement.

Most of the governor’s proposals already exist in the form of agency regulations, guidance or court rulings, but some experts said that the police, hospitals and clinicians would be more likely to follow them if they were enshrined in law.

Ann Marie T. Sullivan, commissioner of the State Office of Mental Health, said that the proposals would affect a “very small select group of individuals” and that after years of shortages of psychiatric hospital beds in the city, there were now enough beds to accommodate them.

She said the measures would “help individuals who make these difficult but important decisions know better how to make those decisions.”