Involuntary transport of people is truly awful
The involuntary transport and psychiatric hospitalizations of street homeless New Yorkers are not new. The law has long recognized the need for such intervention in extreme circumstances, and I have made the painful, but necessary decision to use these tools in my years conducting street homeless outreach. What is new, and alarming, is the misguided expansion of this practice being pursued by Mayor Adams.
Depriving any human being of their autonomy and liberty can never be taken lightly, and New York recognizes how sparingly we must employ involuntary transport. Section 9.58 of the state Mental Hygiene law reserves this practice for someone who is both a qualified mental health professional and a member of an approved mobile crisis outreach team, allowing the involuntary transportation of an individual to a hospital for psychiatric assessment only if they are believed to pose an immediate risk to themselves or others.
During the five years that I served as director of a New York City street homeless outreach team, I requested only two involuntary transports. In each instance, I truly felt that a life was in jeopardy. Transports required extensive preplanning and onsite coordination, and were initiated only under extraordinary circumstances as an absolute last resort after exhausting all other options, which included meetings with our team psychiatrist and intensive exploration of voluntary treatments.
We employed exacting standards and worked to minimize the use of involuntary transport, both as a matter of principle — a fundamental respect for the human rights to liberty and self-determination — and as recognition of a practical and dark reality.
New Yorkers are increasingly attuned to the mental health crisis impacting our street homeless residents, but few are familiar with the conditions they encounter under the approach proposed by the mayor, which can result in traumatizing experiences that are counterproductive to the mental health care needs of an already vulnerable and marginalized population.
Involuntary transports are a cacophonous scene, with sirens and flashing lights, handcuffs and violent restraint. The encounter can exacerbate mental illness, as can the hours that clients are then made to wait in an often overcrowded and chaotic psychiatric emergency room. After admission, care is well intentioned, but necessarily focused on short-term crisis intervention; it is rarely effective at achieving sustainable outcomes, and may instead reinforce long-term treatment resistance.
Involuntarily transporting someone from the street to a hospital was never an act to be celebrated. As a clinician, it meant that I, and a multitude of larger systems, had failed this individual. We had failed to create mental health care services in which they felt welcome and safe, where they saw a viable path to lasting stability. Sometimes, the reluctance to access services may be rooted in symptoms of mental illness, but often, these individuals are making rational decisions to avoid a system unequipped to treat them.
The Adams administration is now seeking to loosen existing involuntary transport criteria to include individuals who appear to be mentally ill and who display an inability to “meet basic living needs,” a highly subjective standard. Safe involuntary transportation demands that an assessing clinician is able to self-reflect and examine how their positionality, education, and training may have created biases that affect clinical work and judgment.
As Paulo Freire wrote, there is no neutral education. I, and most of my colleagues, received our clinical education from universities using a Western framework to teach mental health treatment and psychiatric assessment. The Diagnostic Statistical Manual of Mental Disorders (DSM) — often criticized for being racially and culturally biased — is the guiding tool, and it is through this lens that we would be deciding what constitutes a basic need and pathologizing behaviors misunderstood by us.
The power to transport someone against their will is a great responsibility that can cause harm if not used with extreme caution and careful planning. Even trained clinicians may struggle to employ this approach ethically. And we are now handing this responsibility to the NYPD.
In addition to the risk that Adams’ proposal poses to homeless New Yorkers, there is a high likelihood that this policy would undermine efforts to close Rikers Island. At a time when the city should be enacting policies aimed at decarcerating Rikers, Adams is pursuing policies that will increase contact between NYPD and homeless New Yorkers, a relationship that is already tense and that has the potential to end in arrest rather than treatment.
The mayor has not been using the word removal, but media outlets covering the issue have been. The language used to discuss policy matters, it can dehumanize and create further stigmatization. We remove a stain. We remove debris. And now, we seek to remove human beings.