Late last year, New York City Mayor Eric Adams put into motion a plan expanding the use of force to drug and hospitalize people against their will. While this used to require clear evidence of imminent danger, it now requires only concern that a person may be having delusions or even simply not taking care of their physical health. Some have noted that this is meant to be used as a way to forcibly remove unhoused people from the streets, so it’s no surprise that advocacy groups and activists expressed concern.
The Consumer Advisory Board (CAB committee) I chair for the NYC Department of Health and Mental Hygiene (DOMH), has also expressed concern. So we pressed DOMH for more information and guidance around the new rules for “emergency interventions.”
We wanted to listen to the training about the new rules which was given to clinicians and police officers. What were they being told about their expanding roles?
We also wanted numbers. How many people have been detained, imprisoned, or drugged under the new rules? How does that compare to the previous state of things? How was the sprawling bureaucratic superstructure of city government tracking outcomes on the ground in real time?
DOMH answered our call and offered a presentation. But as the presenter arrived, we quickly realized that this presentation could not be the same one that was being given to clinicians and the police. The presentation was straightforward—and without substance. First, the presenter offered no slides, PowerPoint, or handouts. While supplementary materials aren’t a requirement, data and numbers are when it comes to tracking outcomes in mental health. There were no such figures at the meeting. It seemed as if the presenter waltzed into the meeting and shot from the hip when preparing and delivering this presentation.
The primary focus of the presenter appeared to be defensive—absolving them of any wrongdoing before our advisory board could express concern: “Despite what you read in the news, we are not rounding people up and taking them to the hospital,” the presenter said. Then followed a litany of painfully stereotypical examples of removals in the streets. These examples cited were no doubt meant to convince the CAB that the police and clinicians were working under the proper ethical and humane methods when intervening. Every example was so clear that even the most novice clinician would have opted to hospitalize—and none of them would have required the law to have the newly expanded scope provided by Mayor Adams.
According to a memorandum from the Office of Mental Health (OMH), both sections 9.41 and 9.58 authorize the removal of a person who appears to be mentally ill and displays an inability to meet basic living needs, even when no recent dangerous act has been observed. The city concurs with OMH on this interpretation of the law. If the circumstances support an objectively reasonable basis to conclude that the person appears to have a mental illness and cannot support their basic human needs to an extent that causes them harm, they may be removed for an evaluation. Case law does not provide extensive guidance regarding removals for mental health evaluations based on short interactions in the field. But it suggests that the following circumstances could be reasonable indicia of an inability to support basic needs due to mental illness that harms the individual: untreated severe physical injury, unawareness or delusional misapprehension of surroundings, or unawareness or delusional misapprehension of physical condition or health.
Ultimately, though, the presenter stated that the new rules are permissive, not prescriptive. Even more unsettling, the presenter suggested that the law needs to be permissive, and public welfare and emergency intervention can benefit from the interpretive greyness. I was taken aback by this point. In a prescriptive system, specific situations and criteria must be met before an intervention can be taken. Clinicians and police have to justify how the person before them fits the criteria of requiring intervention.
However, a permissive system could be summed up by the statement, “When in doubt, hospitalize.” From the perspective of the clinician—or police officer—an unhoused person simply has to appear to be “mentally ill” enough that they aren’t taking care of their own medical needs. As if getting medical care is an easy thing for a person with no money to take care of in America!
The foundation of evidence-based treatment rests on being prescriptive—identifying the specific situations that meet criteria for an intervention, especially if the intervention being justified will violate that person’s human rights (say, by forcibly hospitalizing and drugging them). But a permissive type of treatment implies that clinicians and police will err on the side of intervening.
I am apprehensive because the shift in focus outlined in OMH’s memorandum might delay the meaningful conversations we need to have about best practices. There is no question that clinicians, given the mayor’s mandate, are facing higher-than-ever emergency calls in which clinical grey areas blur clinical assessment. In many of these cases, treatment—in the form of forcibly removing people from the streets and drugging them against their will—might do more harm than good.
These grey areas are ones in which the previous standard of danger to oneself or others is not met, but the person still appears to be “mentally ill” and not taking care of their needs “appropriately” (in the eyes of the clinician or police officer). These are the people who, under the expanded rules, will be at risk of losing their rights.
The presenter at the CAB meeting offered a soft solution to this quandary: Supposedly, a “Learning Collaborative” was being created, a team that would cross systems and listen to the unhoused community. This collaboration would, apparently, evaluate real cases and try to figure out best practices for the most troubling grey areas. According to the presenter, a forum where honest discussion would take place was in the works to get this collaboration off the ground.
Sounds like a start. But when the CAB committee members asked how to join this collaborative, it turned out that it hasn’t yet left the pre-planning stage. Of course, anything specific about the collaborative’s start date, how it will work, and who will be allowed to participate is yet to be determined.
The situation couldn’t be any direr for NYC’s unhoused. More emergency teams are on the streets than ever, hospitalizing these folks most at risk of harm. The presenter assured the CAB committee that new removals were fully justified. But, as I mentioned, there was no data to back up her claims. When we requested specific numbers and data, the presenter suggested that there were so many different players, agencies, and moving parts it was hard to “make sense” of all the information.
Lack of information was a big problem at this CAB presentation. Upon listening to the presenter, there was no way to capture the changes in the data and numbers. So, does DOMH know what is happening in the streets? The presenter soft-pedaled a bit at this point, suggesting there was a diagram that made sense of everything. That must be one detailed diagram, I thought! The diagram would have to explain everything the presenter couldn’t verbalize or substantiate with actual numbers and data! I asked to see it.
Houston, we have a problem here. There was no diagram. Nothing was making any sense at this point in the meeting. The presentation culminated in a peer advocate demanding the government release the real training—the one being given to police and clinicians. The presenter refused. I began to sob internally for the people of NYC at risk of harm by clinicians and police carrying out removals without justification or adequate training. Training that the presenter, again, couldn’t share with the CAB committee. Another huge problem for transparency and accountability in DOMH and an example of how ineffectual the CAB committee is when it comes to being involved in the rollout of regulation of mental health practices in NYC.
Ultimately, the presenter had no facts and, even worse, no reasonable accountability or way of knowing what was happening in the streets. We need evidence to evaluate what is happening to real people in New York under Mayor Adams’ plan.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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