Billie Boggs, mental health and homelessness
At the center of the raging and now national debate ignited by Mayor Adams’ plan to involuntarily hospitalize unhoused people with mental illness is the claim that he is impermissibly expanding New York’s involuntary commitment standard, thereby potentially violating a person’s constitutional rights.
According to Adams and state Mental Health Commissioner Ann Sullivan, since the infamous “Billie Boggs” case in 1988, judges have upheld a fairly liberal interpretation of New York’s involuntary commitment standard under the Mental Hygiene Law. Sullivan has said the law does not require a finding of violent behavior or the threat of violence or dangerousness against another to involuntary commitment someone to a psychiatric hospital.
Rather, she says, if police find that there is “an inability to meet one’s need for food, clothing or shelter is sufficient to establish dangerousness to self for purposes of removal from the community for assessment and involuntary admission,” that’s enough.
For many New Yorkers who routinely sidestep unhoused people in obvious mental health distress, this standard is likely to make some sense. For legal advocates like Norman Siegel, the former head of the New York Civil Liberties Union and, much to former Mayor Koch’s chagrin, one of the attorneys who represented Boggs, Sullivan’s interpretation may lack legal authority and is likely to be challenged in court as potentially violative of constitutionally protected civil rights.
Rather than wrestling over the third rail that is the need for involuntary commitment, our energy would be better spent focusing productively on the root causes of homelessness among people with untreated serious mental illness. There is no more time to lose. People suffering on the streets have waited long enough. Passersby and those who help them, like Siegel, have had enough too.
No matter on which side of the constitutional divide you fall, a fair question raised by the city’s approach is this: If New York’s standard for commitment is already so liberal, why are so many New Yorkers with serious mental illness unhoused, incarcerated or prematurely dead?
The problem, Adams says, is that most people, including first responders and clinical staff, are simply unaware of this more permissive commitment standard. But an in-depth report by Maya Kaufman in Crain’s New York Business recently found that the failure to admit people in obvious need of in-patient psychiatric care was purposeful: “Many hospitals refuse to admit seriously mentally ill patients, instead doling out medication to subdue their symptoms and immediately cutting them loose. Some keep lists of particularly violent patients who should be automatically transferred elsewhere.”
The complicated causes underlying this problem seem to have little to do with the standard of involuntary commitment and more to do with funding, capacity and the decades-long, shameful neglect of some of the most desperately ill and poor among us whose care and treatment has been steadfastly denied or undermined since enactment of the federal Medicaid laws and the deinstitutionalization movement of the 1960s.
One serious obstacle to in-patient admittance is lack both of beds and personnel. A primary driver of the continued loss of psychiatric beds relates to Medicaid reimbursement formulas that disincentivize hospitals to provide inpatient psychiatric care, despite the obvious need for more beds. A recent study by the Massachusetts College of Emergency Physicians found that almost 30% of ER beds were “occupied by people experiencing a behavioral health emergency, with some patients remaining there for weeks.”
According to some ER psychiatrists in New York who spoke on the condition of confidentiality, patients can wait in an ER for days before a psychiatric bed opens. Once admitted, patients can remain in locked wards for months awaiting a forensic bed or placement in community-based residential housing.
Given these realities, it’s not hard to imagine why hospitals are incentivized to “treat and street.”
Staff shortages are equally problematic. One upstate hospital is typically only able to fill two-thirds of its psychiatric beds due to staffing shortages. Similarly, the Boston Globe reported that about 20% of Massachusetts’ psychiatric beds are “off-line” due to staff shortages.
These daily realities are churning beneath the constitutional firefight waging between the mayor and many mental health advocates. They must be addressed or history will keep repeating itself.
What’s needed are more CPEPs (Comprehensive Psychiatric Emergency Programs), return of the highly successful Parachute Program, which provided a “safe landing” for people in mental health crisis, more supportive housing and the reforms currently being refined by committees formed following Adams’ successful Gracie Mansion summit in October.
Ultimately, however, this problem needs help at the federal level because a major driver is Social Security and Medicaid policies that disincentivize the creation of psychiatric beds to serve low-income people, some of which have been in place since 1965. While these fixes are and were beyond the control of mayors or governors, they must be priorities for House Minority Leader Hakeem Jeffries and Senate Majority Leader Chuck Schumer. Seizing this moment to implement reforms that will address root causes is key to everyone’s safety.