How New York City is Engaging the Mentally Ill Underground

According to a recent MTA survey, addressing quality-of-life concerns and erratic behavior are the most frequently cited ways to improve rider satisfaction — cited by more than 40% of all riders.

To discuss the City’s efforts to lessen the presence of homeless individuals with serious mental illness on platforms and trains — and more importantly, to get them the mental health help they need — Vital City talked to Brian Stettin, Mayor Eric Adams’ senior advisor on severe mental illness. 

Stettin was hired by Adams after he wrote a Jan. 23, 2022, Daily News op-ed arguing that New York should add psychiatric beds and more aggressively interpret civil commitment laws to give psychiatric providers more authority to get more people into treatment against their will. Stettin formerly served as an assistant attorney general for the state of New York and as policy director of the Treatment Advocacy Center.

Stettin was the chief architect of Adams’ Nov. 29, 2022 plan to try to ensure that more of those in the throes of psychiatric crisis are ordered into treatment, and has been instrumental in subsequent strategies to engage and assist unsheltered people languishing underground. Those include the pilot SCOUT program pairing police officers with mental health practitioners, which by next year will expand from two teams to 10 with the help of $20 million allocated by Gov. Kathy Hochul and the state Legislature.

This conversation has been edited for length and clarity.

Vital City: People with serious mental illness in the subway system: How big is the problem? Who measures it and how?

Brian Stettin: I don’t know that I could tell you a number that I have tremendous confidence in. There’s the HOPE count we do every year, which tells us that we have about 1,500 people who are unsheltered taking refuge in the subway system.

I think our best guess is that about a third of them have serious mental illness. On a given day, it doesn’t necessarily mean that they’re exhibiting any condition where they absolutely have to come out of the system because of that serious mental illness. I think it’s probably fair to assume that we’re talking about a few hundred people.

VC: Do we have a way of measuring whether it’s going up or down?

BS: Not in any way that I have enormous confidence in. Anecdotally, our sense has been that during the COVID period, a lot more people came into the system as beds were repurposed to deal with the COVID emergency. We’ve now reached the point where we’ve gotten those beds back online, and hopefully that’s allowing it to calm down a little bit. 

VC: How many different types of teams interact with these populations underground? The casual observer will have heard a lot of different acronyms by this point. 

BS: The Bowery Residence Committee has a contract with our Department of Homeless Services to conduct outreach in the subway systems. They don’t go on trains, but they have rapport with folks who they encounter in stations regularly, and they were obviously working with more than just people with mental illness. They’re dealing with the homeless down there in general. We also have the state operating SOS, or Safe Options Support teams that have some subway activity. Then of course, our Intensive Mobile Treatment (IMT) and Assertive Community Treatment (ACT) teams that we have operating around the city are not subway-focused, but they certainly will go into the subway system to meet with clients when necessary.

VC: Explain the difference between Assertive Community Treatment and Intensive Mobile Treatment.

BS: ACT is a service that is provided to people who are in the community whether they’re sheltered in a private home, or homeless, who are in need of a team approach to their mental health needs and other needs. IMT is taking that concept in a mobile direction. It’s about focusing on people who are homeless and providing them with psychiatric as well as other services wherever we can find them.

VC: SCOUT stands for Subway Co-Response Outreach Teams. They launched last October. What’s new about the approach, and why does it matter?

BS: Standard homeless outreach, as conducted by the nonprofit partners we’ve talked about, is really about building trust with people over time. 

They are trying to let these folks know that they are there for them, that they can connect them with care and services and housing, and are hoping to build that trust so at some point that person will say, “Yes, I’m ready to come inside. Let’s get me on a path to get off the street.” 

By contrast, SCOUT teams are actively looking for people in psychiatric crisis and opportunities to connect them with medical care as a first step to getting them all the other things that they’re going to need over time.

It’s clinician-led. Police are there as well because we’re basically asking these two types of professionals to each act within their own sphere and do what they do best. We have a clinician there leading that engagement, but we want a cop there as well because it gives a clinician a greater sense of safety as they lean into cases where a person’s behavior might be a little bit scary or threatening.

We also are going to need to have police there at the moment when it’s determined that someone needs to go to the hospital. That’s really what SCOUT is out there looking for: people who are in need of psychiatric care, which is going to be provided in a hospital as a first step on a long journey to recovery. Whenever possible, they’re going to try and persuade people to come along, take that first step on a voluntary basis, but of course that’s not always possible.

VC: The trigger for bringing someone into the hospital is whether they are deemed to be a danger to themselves or to others?

BS: For professionals to make that decision, they’re going to have to find that the person is both exhibiting psychiatric symptoms and that they’re a danger to themselves or others. You’ll call an ambulance to the scene, but getting that person into and off that ambulance is going to require the help of a police officer because this is someone who does not want to go and there is going to be some modicum of physical force required to make it happen.

VC: When you say a police officer, is that literally one police officer on a SCOUT team?

BS: In the case of SCOUT, we are teaming one clinician with three police officers.

VC: So the officers are there to flank the clinician and be there to support the clinician if the clinician needs help?

BS: They want to make sure that the clinician can operate in a zone of safety. Once they’ve done that, they really do step back and it’s not going to be all three officers who even take that first step. We don’t want to scare the person and give the person a sense of alarm. It’s generally a single cop who will make sure that there’s an opportunity for the clinician to do their work in safety.

Then the engagement itself is handled by the clinician and they’re going to try and assess the person, get a sense of their needs and pull out all the stops to get that person to agree to come to the hospital voluntarily. If and only if the determination is made that the person needs to go to the hospital and isn’t willing to go voluntarily will all three police officers be brought closer to the person and become involved in bringing them there.

Starting Small

VC: How many SCOUT teams are there currently and what is the plan for growth? Are they just going from train to train and platform to platform, or is there a different strategy as to how they fan out and engage with people?

BS: Currently, we’re operating just in a pilot phase with two teams in Manhattan, 8:00 a.m. to 4:00 p.m., Monday to Friday. We have one team covering 59th Street and below, and the other team covering the northern part of Manhattan. We have some ambitious plans for how SCOUT is ultimately going to work as we ramp it up.

We very much expect to move to more of a dispatch model than we are currently using, where reports from station agents or MTA employees, and maybe even the public through social media, will be responded to. Or we’re going to send SCOUT teams to particular stations, or even at some point on moving trains where we know there are incidents taking place that require their attention.

In this early phase, they are operating more by gathering in the morning and deciding what stations they want to hit that day and patrolling certain stations where they know there’s a high frequency of people who are unsheltered, some of whom are going to be in psychiatric crisis. 

VC: It’s a very small pilot. What do you think is the right number of these teams to actually address the problem as you see it?

BS: We’re going to hopefully get to five teams by the end of the summer, with one in each of the outer boroughs of the subway system. The $20 million in funding that the governor has pledged to this is going to allow us to get up to 10 teams by the end of next year.

VC: Ten teams by the end of next year — does that start to feel to you like it’s responsive to the size of the problem?

BS: I think we’re feeling our way as we go here to some extent, to be honest with you. I do think it’s going to be able to make a significant impact. I think that when you have 10 teams operating in the subway system, that’s going to be enough for SCOUT to be a regular familiar presence to subway riders. Again, I don’t think we’re dealing with a huge number of unsheltered people in psychiatric crisis.

VC: What is a cop supposed to do if he or she is not with a psychiatric practitioner or social worker but sees someone in psychiatric crisis? 

BS: The Mental Hygiene Law allows a police officer to make a determination just as a clinician would, that somebody appears to be mentally ill and is acting in a way that exhibits danger to self or others such that they should be brought to a hospital to be evaluated by a physician. 

They’re not diagnosing somebody. They’re not saying, “This is someone who absolutely needs to be hospitalized.” But rather, “this is someone who needs to come to a hospital to be seen by a doctor and evaluated.” That is a determination that does not necessarily require clinical training, so a police officer can do that. They’re responding to everyday symptoms of mental illness and a common-sense definition of what it means to be a danger to yourself or others.

We prefer to have clinicians do it because they are more skilled at persuading a person to come voluntarily. It’s less triggering, and we’ll ultimately have a better success rate of getting that person admitted to the hospital because the clinician will come along and be able to speak to the hospital staff as a peer and make a case for admission that’s much, much harder for a cop to do.

The ‘Top 50’ List

VC: Readers have probably heard of the “top 50 list” of homeless people at risk. What is it and how does it relate to the folks who might be encountered? If I’m a SCOUT team member or a cop and I encounter someone on the top 50 list, is there supposed to be any particular thing that happens?

BS: Being on the top 50 list doesn’t give a person any different status in terms of whether they need to go to a hospital. 

Their presence on that list is going to become important once we get them to the hospital, though, because we’re going to want to make the hospital aware that they are dealing with a client who has been through that revolving door.

We should take that into account when we’re assessing a person. It should make a difference when we are determining whether they meet the criteria for hospital admission. That’s not a decision that should be made in a vacuum. 

It also becomes important when we are planning discharge for that person. Inevitably, as they get better and stabilize and we’re ready to bring them back into the community, we are able to prioritize their access to the very best we have in terms of shelter resources and ultimately housing resources when we have identified somebody as a member of that list.

VC: You can bring a person in crisis to a hospital, but you cannot make the psychiatric system treat them via assisted outpatient treatment or put the person in an inpatient psychiatric hospital bed. Talk about the complexity of shifting the culture among practitioners to try to make involuntary treatment more accepted and more frequently employed. 

BS: When you encounter somebody in psychiatric crisis, you’re thinking in terms of how to get them to a better place where they can come back into the community and live stably and securely. There are many things that have to happen along the way. The first step is to get them to the hospital. The second step is to get them admitted to the hospital and stay there long enough.

There’s no question that our ability to do that, to accomplish both of those things as those initial steps, has been complicated by this pervasive misunderstanding of legal criteria. There has historically been a notion that a person is not a danger to themselves unless they’re suicidal or engaging in some outrageously dangerous conduct, such that there is an imminent risk of harm to them. Of course, the law itself does not require an imminent risk of harm. That’s a myth we’re trying to puncture.

There is case law that makes clear that another category of people who are dangers to themselves within the meaning of the law are folks who by reason of their mental illness are unable to meet their basic human needs of food, clothing, shelter and medical care. So making that universally understood has been a priority of this administration through the training we’ve provided and through the ongoing dialogue we’re having with all the professionals who are involved in interpreting that law.

Health + Hospitals, our city-operated hospital network, is a major partner in that. Certainly, leadership is very much on board and has been involved in providing that training to the staff and the hospitals. I’ll also say a major factor in having the law interpreted appropriately is ensuring that we have enough beds to give people the extended care that they’re often in need of when they’re coming from an unsheltered environment and they’ve experienced the ravages of homelessness.

VC: Are more people in psychiatric crisis who are found in the subways or the streets getting treatment?

BS: One place where we can really see a difference is in what’s happening to people who are on these top 50 lists. We operate two of them, one for folks entrenched in the subway system, another for those who are known to street locations. If you just look at the difference in how successful we’ve been in moving people out of those unsheltered environments into care in the year plus since we have been pushing this culture shift, you really do see that it is making a difference.

These top 50 lists, I should say, predate this administration. They were started in 2019, as were the weekly meetings about the clients on those lists. 

In 2022, 22 people from those lists were admitted into a hospital or a shelter or housing environment, and we boosted that to 54 people from the two lists in 2023. That is largely because we have been more willing to use the tool of involuntary removal and retain people longer in hospitals.

The Role of the Public

VC: You mentioned earlier that if a member of the public sees somebody, maybe someday there will be a system whereby the SCOUT team follows up on that report and responds to the person in crisis. But we’re not there yet. So today, what would you say is a responsible thing for an ordinary member of the public riding the trains — if they see somebody ranting, seemingly unstable, what should they do? 

BS: Obviously, if there is a police officer nearby, or if you hear an announcement that there’s a police officer on the platform when you come to a stop and you peek your head out and can flag one down, that’s obviously the best way to handle a situation like that. If the person is able to get off the train and talk to a station agent or station manager about what they observed on the train they just got off and can report the car number, it’s very important. That can possibly allow us to get some help to the scene.

I would say in a more typical situation where you are riding the train and have to get to your destination and can’t get off, and you’re seeing somebody in crisis with no police officer around or involved, I think it’s a pretty tough situation for an average citizen to do anything about. I would not advise recording the person in a way that could be observed and could trigger that person’s anger. I wish I had an answer to the question of what you can do in that situation. I think many of us have been there, and the reality is you grin and bear it and hope nothing bad happens in most cases.

VC: What’s your definition of being in crisis? Ranting and raving? Directly threatening people? Something else?

BS: There’s two aspects of it. They have to be exhibiting psychiatric symptoms and then there has to be some reason to think they’re a danger to themselves or others. 

The idea of psychiatric symptoms, I think, is reasonably straightforward. Obviously, there are some symptoms that a clinician will recognize that a layperson won’t, but think about things like responding to internal stimuli, appearing to be talking to someone who isn’t there, someone who is clearly experiencing hallucinations or delusions, someone who may be catatonic or just behaving in a way that appears that they are under a certain kind of disturbance.

The danger to self or others part, again, includes more than just acting out in a way that’s threatening. It also includes a person who’s doing a really poor job of basic self-care. Again, it has to be in combination with those psychiatric symptoms. If you observe someone who is extremely disheveled and unclean, who is emaciated, who appears to have some medical needs that have been unmet, who may be exposing themselves in a way that is unsafe or likely to lead some bad outcome, all that certainly counts, and those are things that we can respond to.

VC: Is it responsible and advisable for a member of the public to call the City upon encountering such an individual, assuming that they’re not exposing themselves to any danger? If so, where do they call?

BS: It’s certainly helpful with respect to people whose location can be reported in some reliable fashion. If it’s somebody who you regularly see outside of a particular building or in a particular station, calling 988, triggering our crisis response system to come take a look at that person, is a great idea. If it’s someone who you’re seeing while you’re in motion on a train, it’s going to be very hard for anyone to respond in time to actually find a particular person you’re talking about. Frustratingly, until we get SCOUT to another level of operation, I think it’s really hard for me to suggest that we’re going to be able to do much with the information.