Ghosts of Deinstitutionalization

No one is happy with the legacy of deinstitutionalization. At their peak in 1955, state mental hospitals in the United States held nearly 600,000 people — almost as many per capita as the U.S. incarcerates in prisons today — but over the next two decades that number fell dramatically. The hospitals had been discredited by accounts from former patients and muckraking journalists that exposed them as brutal and expensive warehouses for people who society had given up on, and as places whose promises to provide meaningful treatment were routinely broken.  Many of the people who were released or diverted from the hospitals thrived in the community, but too many others have struggled. 

Police became the first point of contact for many of the people that deinstitutionalization has failed, and they knew how badly those people were suffering and how poorly they were being served before almost anyone else. A wide range of people call the police about mentally ill people living in the community — family members, landlords and business owners alarmed by their behavior or concerned about their welfare, but also staff at homeless shelters, schools, supportive housing facilities and even mental hospitals which find themselves unable to manage people they are supposed to be caring for. These are not easy situations for the police to handle. Many people, including police officers themselves, wish these situations could be reassigned to someone else, but for a variety of reasons (including the dangers that some of these encounters pose and the potential need to resolve them with coercive authority) it has proven difficult to take police out of the equation altogether.

The continuing debates about how the police should understand their role in these encounters — including the debate prompted by Mayor Adams’ recent call for wider use of involuntary removals for psychiatric evaluation — are shaped by tacit assumptions about the purposes of deinstitutionalization and the reasons why it failed. Those assumptions need more scrutiny than they have received because, consciously or not, policy-makers are reacting to the framework deinstitutionalization established.

Treatment and Control in the Community

The most common view of deinstitutionalization interprets it as a shift in the location where mental health treatments are delivered to individuals — an effort to vindicate the “right to treatment” that the state mental hospitals had made such a mockery of. The invention of medications like chlorpromazine and reserpine in the 1950s — originally used to tranquilize disruptive patients inside the state mental hospitals but soon championed as potential cures for schizophrenia and other serious mental illnesses — buoyed hopes that many people could live successfully outside the hospitals if a system to distribute treatments in the community could be devised. These hopes contributed to the massive policy efforts to develop a network of community mental health centers to replace the state mental hospitals. In fact, the new medications and mental health treatments delivered in the community did help many people with serious mental illnesses lead better lives, but the cures that were always suspected to be just around the corner never materialized, and the infrastructure needed to consistently deliver mental health treatments in the community has always remained anemic. 

These failures did not necessarily discredit the underlying goal of relocating the site of psychiatric treatment from the hospitals to the community; they simply indicated that the task required more resources and social coordination than its champions originally recognized. Effective delivery of treatment in the community requires a broad network of partners to help ensure that mentally ill people did not fall through the cracks — sufficient capacity among treatment providers, most obviously, but also the cooperation of the network of people who have regular contact with psychiatric patients (such as family members or landlords) to help keep them engaged with their treatment and alert the treatment providers when difficulties arise. The police are a crucial part of that network because they are a major point of contact with people with serious mental illnesses when problems arise in the community and because they have the authority to enforce the system’s mandates when voluntary cooperation is not enough. 

Adams’ initiative aims to strengthen this role for the police. Most visibly, it does so by trying to change what he described as the “culture of uncertainty” around the scope of police authority to take someone into custody for psychiatric evaluation by dispelling the “myth” that officers cannot take that step merely because they believe someone can’t meet their basic needs. Less obviously, it does so by calling for wider use of mandated community treatment for patients discharged from inpatient settings; inevitably, the police will be involved in enforcing those mandated treatment orders. (California’s recent mental health initiative also leans heavily on mandatory outpatient treatment, which may ultimately affect more people than the more attention-getting push to expand involuntary removals for psychiatric evaluation.)

Police officers themselves are often uneasy with this role. They know they are not clinicians, and they find it hard to distinguish between people who are merely acting eccentrically and people who genuinely pose a danger to themselves or others, or between behavior that results from a temporary condition like intoxication and behavior that results from a chronic condition like schizophrenia. That is particularly true when it comes to the specific criterion for involuntary removal the Mayor’s announcement emphasized, which focuses on people who cannot meet their basic needs (rather than people who are a danger to others or an imminent danger to themselves).  It is one thing to seek involuntary psychiatric evaluation of someone like Andrew Goldstein who had repeatedly attacked strangers in public before he pushed Kendra Webdale into a subway car in 1999. But it is quite another to seek it for someone who is non-violent but may not be able to take care of himself (especially based only on “short interactions in the field”, as the memo announcing the Mayor’s initiative conceded). 

Even when an officer feels confident that someone needs psychiatric help but refuses it, she may think it is futile to bring them in for evaluation when she has little faith that the system has the capacity to meet their needs. Police are more comfortable executing commitment or treatment orders issued by judges and clinicians, but even in those cases they may have reservations, and they do not like being asked to do the mental health system’s dirty work. (Whoever wrote the memo announcing the Mayor’s initiative felt it was necessary to stress that police must fulfill such orders “even if the officer disagrees about the need for involuntary transport”). New York police already involuntarily transport thousands of people a year for psychiatric evaluations, and since 2017 the Civilian Complaint Review Board has received nearly 2,700 complaints about those interventions.)

Concerns like these are hardly unreasonable, and they cannot all be alleviated by giving officers access to telehealth consultations or providing the officers additional guidance and training the city has promised. (With so much at stake, it is unclear why the Mayor announced this push before the details were in place. Many officers may have already concluded that they are being set up to fail once again.) Many people have good reasons to refuse treatment. Medications may have intolerable side effects and fail to provide the relief they promised, and psychiatrists themselves recognize how difficult it is to find an appropriate treatment for many complex conditions; involuntary confinement to a psychiatric hospital is among the most traumatic and stigmatizing experiences anyone can undergo. Medical and therapeutic interventions can provide valuable and even life-saving help to some people with severe psychiatric disabilities, but they cannot help others, and sometimes they hurt more than they help. Efforts to extend the reach of community-based psychiatry eventually run up against not just a paucity of resources but also the limits of psychiatric knowledge and technique. (When pressed by reporters to describe what happened to the 1,300 emotionally disturbed people that city police have already removed from the subways to the hospitals this year, the city could provide no information. We cannot assume that involuntary removal will actually resolve whatever problem supposedly prompted it.) 

Those who defend the Mayor’s announcement chide his critics for their lack of compassion for people living in desperate circumstances, and they insist that it is naïve to believe that coercive intervention is never justified. But it is also naïve to believe that coercive interventions will only ensnare people who will actually benefit from them — they will inevitably be applied more broadly because it is difficult to identify perfectly all those and only those for whom removal and ultimately commitment is a good idea — and we should also have compassion for the people who have been profoundly harmed by psychiatric intervention or simply cannot be helped by it.

Building an Inclusive Society

A humane and effective strategy for addressing the crisis of serious mental illness in cities like New York will require us to rethink what deinstitutionalization was about and why it failed. When American society shut down so many mental hospitals, the goal was not simply to move treatment into the community. The goal was also to build a more inclusive society, returning people who had been segregated in hospitals to their families and neighborhoods where they could live less constricted lives. That goal required more than efforts to relocate clinicians from hospitals to community settings. It required efforts to restructure the social environment to make it more hospitable to people with psychiatric disabilities, which cannot always be cured and, when they can, often have social rather than neurochemical or other individual-level sources.

Deinstitutionalization of the mentally ill was part of a broader movement to vindicate what the great blind activist and scholar Jacobus tenBroek described as the “right to live in the world” — a movement that aimed to restructure social institutions and community practices to make it possible for people with a wider range of physical, cognitive, and emotional capabilities to live alongside one another, rather than consigning them to segregated institutional settings. The target of that effort was not individual change but social transformation. It insisted that we should not view people with psychiatric disabilities simply as patients to be cured but as citizens who must be included in society as equals. It required more than new ways of dispensing psychiatric services in the community. It required supportive housing, flexible jobs, responsive schools, capable families, tolerant communities, and other social arrangements that make it possible for people who differ from the “average” tenant, worker, student, son or neighbor to succeed in their role. The visible suffering we see on too many city streets may result as much from our failure to accommodate the distinctive capabilities of many disabled people as from failures to dispense the available psychiatric treatments. Regardless, the imperative of accommodation carries less risk of harm than the imperative to extend the reach of community-based psychiatry through coercive means.

This alternative vision does not obviously involve the police, for it places less emphasis on controlling individuals and more emphasis on accommodating them — less on the individual’s duty to conform and more on society’s duty to accommodate. But those social duties need to be policed as well. Just as police officers often learn before anyone else when individuals are struggling, they may also learn before anyone else when the social infrastructure required to meet their needs is failing. Like the other problems that police deal with, mental health calls are concentrated in particular times and places. Some of those places may suffer from problems like poor management and inadequate staffing, and the police and regulatory bodies may be able to encourage, support, or force those in charge of them to fulfill their responsibilities to vulnerable individuals more adequately. A shelter or supportive housing facility may repeatedly call 911 because its staff feel unprepared to manage residents with serious mental illnesses; a family may repeatedly call because its members do not know how to prevent or manage their daughter’s frightening outbursts. In September, Maya Kaufman reported on a New York City shelter whose staff repeatedly called 911 because they were “overburdened and ill prepared to work with residents with serious mental illness” but refused to participate in training for crisis management and de-escalation. In cases like these, focusing on the treatment needs of the individual with a serious mental illness is too narrow. The problem is that the environments where those individuals live lack the capacity to meet their needs. 

The police often know where these failures are concentrated, but we rarely encourage them to relay that knowledge to those who can demand change. In the meantime, officers complain amongst themselves about the institutional failures they repeatedly encounter. During her extensive fieldwork on the police response to mental health crises in Los Angeles, Natalie Pifer witnessed patrol officers’ deep frustration with institutions like group homes and schools that repeatedly call police to manage people with mental illnesses, complaining: “Shouldn’t these places be able to do their job?” 

Occasionally, police departments have pressed that issue more forcefully. In one English parish, the police became exasperated with a supported housing facility’s repeated failure to deescalate incipient conflicts that eventually required a police response — management had clearly failed to provide adequate staff and training or to follow the individualized plans that each resident had — and eventually brought the problem to regulators’ attention. Within weeks the facility’s leadership and staff had changed, and the environment in which the residents lived had been transformed. Police leaders committed to Herman Goldstein’s influential idea of “Problem-Oriented Policing” have particularly stressed the need for interventions like these. Thoughtful police officers have helped overwhelmed families and others access the help that is available to them to manage and forestall difficult moments with their loved ones. In all of these cases their goal is not to coerce a recalcitrant patient into treatment but to build a world that can more effectively accommodate that person’s distinctive capabilities. This agenda is not a utopian vision that will only have an impact in the distant future. It is an immediate imperative to scrutinize and try to reform the institutions and social arrangements that fail to accommodate the distinctive capabilities of individuals with psychiatric disabilities at least as intensively as we scrutinize and try to reform the individuals themselves. 

The imperative of accommodation has its own limits. The problem that sparked Adams’ current push to address chronic mental illness is the problem of public disorder in the subways and the streets. As I have written elsewhere, rules of public order are important, and when people violate them it is entirely appropriate to intervene as long as the intervention is as restrained as possible. But an initiative that is centered on the claim that it is legitimate to commit someone even when he only poses a threat to his own welfare is by definition not about that. In that respect, Adams’ announcement confused the problem of public order with the problem of mental health. The confusion is dangerous given how delicate and complex it is to try to extend the reach of community-based psychiatry against its targets’ will. There have already been reports that officers have threatened unsheltered people that they will have to “go to the hospital” if they don’t leave the subway. If those reports are true, they would reflect an egregious abuse of the purpose of the involuntary removal law. It is worth debating whether MTA rules should prohibit loitering or sleeping in a subway station, but it is wrong to use the involuntary removal provision of the Mental Hygiene Law as a pretext to accomplish that end. 

By focusing his new mental health initiative on involuntary removals for psychiatric evaluation, Mayor Adams put our attention on efforts to change vulnerable individuals, against their will if necessary. Sometimes those efforts may be necessary and appropriate, but police officers and the rest of us are right to be uneasy with them. In any case they should not distract us from the further need to build a society where those individuals can live with dignity and care on terms they choose themselves. The needlessly narrow view of what deinstitutionalization was about that has dominated thought and action in this area has trapped us in a dilemma that pits freedom against care and blinds us to possibilities that can expand both.