Title: 30 Issues in 30 Days: Involuntary Hospitalization of Mentally Ill New Yorkers

[MUSIC]

Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning, everyone. We begin today with today's installment of our 30 Issues in 30 Days election series. Today is Day 7 with Issue 7. When is involuntary hospitalization good or necessary for people seeming to be a threat to themselves or others in New York City because of mental health problems on the streets or in the subways?

I think it's fair to say, we'll see what our guests think, that, roughly speaking, Andrew Cuomo and Republican Curtis Sliwa are fairly similar on the need for more involuntary hospitalization. Eric Adams was, too, and had already increased its use as mayor, as many of you know. Here's Sliwa in a video he released before Adams dropped out, so you'll hear him criticize Adams here. The video shows Sliwa about to give some food to someone sleeping on the street as the candidate addresses the camera.

Curtis Sliwa: It's really sad. 55th, right in the heart. One block south, 7th Avenue, Carnegie Hall. This poor soul lives here every day. The Eric Adams administration does nothing about this. Nothing. They talk about, "Oh, we're taking care of the homeless, the emotionally disturbed. This man is in dire need of help. Now, I'm not the mayor yet. I can't get him into a mental health facility.

I can't clean him up. I can't get him out of this squalor, but I can certainly feed him. There, by the grace of God, goes any one of us. Adams doesn't understand this. Cuomo released them from the mental health facilities, and Zohran Mamdani has no plan for them other than to house them in subways. Here you go, sir. Sir, here you go. A sandwich, okay? And a bottle of water here.

You need the water desperately, don't you? You need that water, okay? Now, what's your name? Oh, God. Curtis. That's right. Man, I'm telling you, if I become mayor, I'm going to help all of your fellow brothers and sisters out here in the streets of the subway. Curtis. Now, all right, enjoy your meal. Enjoy your meal. Thank you. Thank you.

Brian Lehrer: We'll get more into Sliwa's views as we go. You heard his criticisms there of Mamdani as not having a plan, of Cuomo as releasing them, I think he put it. The most different is the Democratic candidate, Zohran Mamdani, who wants to create what he calls a Department of Community Safety. Here's a clip of him at a Columbia University Journalism School forum hosted by the public safety-oriented journal Vital City. He was asked what would happen under that plan when the Department of Community Safety becomes aware of a person in an acute or seemingly ongoing mental health crisis.

Zohran Mamdani: You would have teams of three. In those teams, you would have an EMT. You would have a peer, because we've also seen time and time again that having a peer present in these interactions is critically important. I'll give you an example of how this could work. In Denver, they had a STAR program. This is a program that focuses on low-level crime. In the neighborhoods where they focused, that crime went down by 34%.

Over the period of a number of years, they had 12,000 clinical interactions. Of those, only 3% required a medical hold. I say this because oftentimes in this conversation around subway safety, in the conversation around mental health, there also comes a question of involuntary commitment. What I have said time and again is, it's outcomes, it's evidence, and reading some of the research around involuntary commitment, not being fully convinced that this actually has the outcomes that we hope that it would in terms of remedying this, but saying that this would be a last resort. However, the first resort has to be actually engaging and interacting.

Brian Lehrer: Zohran Mamdani at a Vital City forum on homelessness and related issues. We could not find a clip of Andrew Cuomo talking about this, but he does address it on his website. As we go, we will read from the Cuomo campaign website to represent him. We have two guests to discuss this topic and contrast their own views and those of the candidates, including the question of when involuntary hospitalization is in the interest of the person being committed and when it might be more to make other people feel more safe or less imposed upon, and if that's okay.

My guests are Brian Stettin, currently a senior advisor on severe mental illness for the New York City Mayor's Office, and Michael Hogan, who was the New York State Commissioner of Mental Health from 2007 to 2012. He is now a consultant at his company, Hogan Health Solutions. Brian and Michael, thank you both for engaging on this. Welcome to WNYC.

Michael Hogan: Good to be with you.

Brian Stettin: Thank you so much. Great to be with you.

Brian Lehrer: Brian, since you're doing this work now for city government, I'll start with you. Even though Mayor Adams is no longer in the race, I think his policies as mayor have pushed this topic and debate over this policy onto center stage in the City, so why don't you take a few minutes and lay out what you think has changed under Mayor Adams and why it's been a good thing both for the people involuntarily hospitalized and for members of the public who might encounter them.

Brian Stettin: Sure, and thanks so much again for having me on. I think there's been an unfortunate media narrative around Mayor Adams' policy on this, as though this is the centerpiece, or maybe sometimes even the whole enchilada of our approach to addressing severe mental illness in the community. We've tried very hard to make clear, I think sometimes it gets lost in the kind of sensationalism that surrounds this issue, that this involuntary removal policy, it's a leg of the table, right?

It's nothing more than that. It's also nothing less than that. It really has to be understood in the broader context of everything that we are doing to make sure there is a great public mental health system to commit people into so that this is not all just a hollow exercise. If you look at the entire record, things we've done, like the Bridge to Home model that we've now just introduced on the West Side, this kind of innovative living facility for people who are ready to be discharged from the hospital but don't have a place to go and still need intensive psychiatric services, the 1,400 new Safe Haven beds that we put out, and 900 or more of those that we have in the pipeline, the doubling of the number of clubhouses in the City, the more IMT slots.

We can get into all these programs. The point being, we're doing a whole lot to fix a broken mental system that's really suffered from decades of dysfunction and takes some time. Really, it can only be really done incrementally to make that a robust, great system, but in the meantime, we have absolutely leaned in and embraced the importance of involuntary removals as one element of what that system has to be.

This is not something that we think we have to be apologetic about or view as a last resort when all other systems have failed. It's a recognition of the reality, the cruel reality of the kinds of psychiatric illnesses that we're dealing with out there, schizophrenia and severe bipolar disorder, most prominently. These are diseases that often make it impossible for a person to recognize that they have psychiatric needs.

When we're encountering somebody in the community who is in acute psychiatric crisis and cannot recognize that for themselves, they lack insight, they're so disconnected from reality that they don't know what their needs are, we have a moral responsibility to get that person into the system. Any opportunity to connect them with all those other good things I just mentioned really starts with stabilizing them psychologically, getting the medications right, keeping them in the hospital long enough so that we can give them a fighting chance to do well when they come out.

I really think we've done a lot to change the culture on that, really, starting with a broadening of the understanding of what it means to be a danger to oneself, which is one important part of the legal standard to remove people. There had been a pervasive misunderstanding throughout the system that a person only met the criteria for this kind of removal when they were imminently dangerous, that is, when they were acting out in some way that created this immediate need.

They were violent, they were suicidal, engaging in some outrageously dangerous conduct. What I think we've done differently, the message that we've gotten out to the people we have on the ground who are making these kinds of decisions is that a person who is not meeting their basic human needs as a result of severe mental illness, we're not just talking about someone suffering from poverty, but someone whose mental illness is causing them to be filthy or emaciated or neglecting some medical condition that's going to fester over time, we don't have to wait till the moment they're on death's door to where that risk of harm to them is imminent to say, "This is somebody we can help and bring in."

We've done a lot to make those kinds of removals, which are a small percentage of the total number of removals happening citywide, more common. We have many people who have been rescued from really dire fates as a result of us taking more ownership of that authority. I'd also say we managed to get the law amended on this as well to make that authority more explicit.

Brian Lehrer: Yes, I see we're already getting a number of calls on this. This is a hot-button issue in New York City, as everybody knows, so let me put out the phone number for everybody, for calls or texts. Listeners, who has a question or a comment, or a personal experience relevant to the question in our 30 Issues election series today, when should involuntary hospitalization be used in New York City for people with severe mental illness?

212-433-WNYC, 212-433-9692. Call or text again with a question or a comment, or a personal experience. You can help us report the story regarding this question about severe mental illness and involuntary hospitalization. Call or text 212-433-9692. Brian, let me ask you one follow-up question before we get Michael's basic take on this, only because it's starting to come in already from some of the listeners.

I know it's going to be a main theme from at least one point of view, and that is the mayor isn't really doing this, and those who advocate for more involuntary commitment, including Cuomo and Sliwa, aren't really doing this so much for the sake of the people in need, more for the perception of safety or even just being grossed out by having to pass these people on the street or in the subway on the part of the general public. What's your response to that?

Brian Stettin: Yes, I wholly reject that framing of it. I think that there's a false choice that people have sometimes in their mind that there is some tension between the very reasonable expectation of people to be able to enjoy public spaces and walk through their neighborhoods and subway system without fear or concern that somebody might harm them on one hand, and on the other hand, the need to actually get help for people who might be creating that fear in others' minds by no fault of their own.

I think the solution to both problems is the same, which is to get people care and to suggest that we are motivated by one and not the other. You can never really look into somebody's heart. I can tell you that I've been a mental health advocate working on this issue for 26 years. I came to this administration because it was very clear to me in my initial conversations with Mayor Adams, after he had read something I had written on this issue, that he cared deeply about the suffering of people with severe mental illness. I think we're addressing both really compelling needs at the same time by getting people into care.

Brian Lehrer: All right. Now, Michael Hogan, former New York State Health Commissioner and now a consultant, I guess, with your own company on these kinds of issues. Why don't you take a few minutes and respond to anything that Brian's been saying and tell us when you think involuntary hospitalization is in the interest of both the person themselves and the general public, and how much you think the Adams' policies have been successful or in the public interest?

Michael Hogan: Well, thanks. Hi, Brian. It's good to be with you. We may find out that Brian and I agree more than we disagree about all this, I guess. I have a little bit more of an introduction. There are two other potential qualifications of mine related to this. One is that the less important is that I chaired President George W. Bush's Commission on Mental Health, the last national presidential commission we had on this topic, so I've seen this around the country.

The second is that I have a family member with serious mental illness and have been involved in that individual's commitment and involuntary treatment, so I see this not strictly from a 30,000-foot point of view. I agree with almost everything that Brian has just said. The one thing that I would throw into the mix here is that what we've seen all too frequently and what we may be at risk of seeing again in New York is making the first change, which we've discussed, and that is to make it clearer that it's possible to involuntarily commit people for treatment, but not doing the rest of the work to produce a system that's going to work for people.

These conditions that Brian has described, nobody should be under the illusion that anybody's going to be cured of them while in a hospital, number one. Number two, nobody should harbor the illusion that they're going to stay in that hospital forever because that violates lots of stuff. The unfortunate reality is that a lot of the debate about involuntary commitment, to me, is something like putting a Band-Aid on a tumor.

It might look good for a while, but it's not going to solve the underlying problems. Some of those other steps that Brian described are more likely to begin to solve that problem, but this is a tough problem. We've never gotten this right in the United States, and it's even tougher in a big urban area like New York City, so my objection is not so much with the involuntary hospitalization per se, but with our systematic failure to do everything that it takes to provide a modicum of a decent living for these individuals and resorting in public debate to what are essentially performative solutions, not real solutions to what is a deep, complicated problem.

Brian Lehrer: Well, maybe that's a good place to start looking at the candidates' proposals, per se. I mentioned that I would read from Andrew Cuomo's campaign website on this, and I want to get both of your takes on how different either of you think Cuomo's and Curtis Sliwa's positions on this issue are from what we've been discussing with respect to Mayor Adams. Then also we'll get into how different Zohran Mamdani's proposals certainly speaks differently about the issue, or in fact, from either of the other two.

On Andrew Cuomo's website, he has a 14-point plan called Addressing New York City's Mental Health Crisis. I guess, Michael, kind of to the point that you were just making, it has to be about more than involuntary hospitalization. It begins with points like Proposal 1, increase the supply of supportive housing units for the seriously mentally ill; Proposal 2, expand access to community-based mental health services and supports, but then eventually it gets to Proposal 12, which I think is pretty strongly worded, consistently enforce involuntary removal and involuntary commitment laws; ensure consistent application of the newly codified basic needs standard for involuntary removal and involuntary commitment by strengthening execution and accountability across city agencies.

Then he does go on to provide an aftercare guarantee upon discharge, but on the first part of that, Michael, "consistently enforce involuntary removal and involuntary commitment laws," do you think that's different from what's being done now, and if you've looked at each candidate, do you think it's any different from what Curtis Sliwa is proposing as the Republican nominee?

Michael Hogan: Well, I don't know. I'm an upstate guy, so I'm not paying that much attention here to these issues, but it feels to me like, in a way that the Cuomo proposal buries the lead in that it feels to me like the lead is "Get them off the streets." Then there's a lot of other stuff that sounds pretty good, but I'm dubious that it's likely to get done. The need for supported housing is unquestionably one of the core elements of what it would take to do this right.

New York has developed more supportive housing for people with mental illness than probably any state, except California, on the one hand. On the other hand, at some point when I was Commissioner, I looked at this problem. I was trying to think, "Can we build supportive housing to get our way out of this problem?" and realized that at this time, when I was doing this back-of-the-envelope analysis, we had about 40,000 supported housing or community housing units of one kind or another in New York for people with mental illness, most of them, or majority of them in the in the City, but at the same time, New York City--

Brian Lehrer: This is back when you were the State Mental Health Commissioner, 2007 to 2012.

Michael Hogan: Yes. We developed 40,000 units of supported housing by this time, but New York City was losing 40,000 units of affordable housing on the marketplace every year because of gentrification and other price demands, so this is very hard work. The test for me, it's not so much about the issue of getting people off the streets who are really in extremis. It's kind of hard to argue with that.

It's much more like, "Are they going to get care that is good enough to help them turn their life around?" I worked in lots of states and for lots of governors, and maybe done, with other people, some good things, but it's kind of hard to be the administrator of this contract between the mentally ill and society when society doesn't want to do what it takes to get the problem done right.

Brian Lehrer: Brian from the Mayor's Office, I'll bring you back in here in just a minute. Michael, since you brought up the decreasing relevant housing supply for people with severe mental illness during the period that you were State Mental Health Commissioner, 2007 to 2012, part of that was when Andrew Cuomo was governor. A New York Times article comparing the candidates on this said, in 2011, when Mr. Cuomo was the governor, he eliminated state funding for a rental assistance program that helped families move out of New York City shelters.

The number of people in the City shelter system then quickly spiked. The City developed a replacement program that is paid for without state funds, and then it continues. When asked about cutting state funding as governor, Mr. Cuomo told POLITICO, "It was 100 years ago," adding that he did not remember what happened with the program he defunded. Since you would have been State Mental Health Commissioner at that time, did The Times article get that right?

Michael Hogan: I think so. If we went back several hundred years, we'd find that Mr. Cuomo was also Secretary of HUD back in the Clinton administration. I don't know, my observation of those times was not that we made big breakthroughs in support of housing.

Brian Lehrer: Brian, you want to get back in here from your point of view on any of what we've been discussing?

Brian Stettin: Yes. Look, the plank in the former governor's platform that you asked for comment on, I have no problem with. Substantively, as just a comms matter, I probably would have used the word "apply the law," rather than "enforce the law," because I think "enforce" gives people the false impression that this is about some punitive measure, or this is about police criminalizing mental illness, which the policy absolutely is not about.

I think it's absolutely appropriate to ensure that every person who we encounter who meets the criteria for involuntary removal, that is, they are exhibiting symptoms of untreated mental illness, and they are, at that moment, a danger to themselves or others, and we're defining that a little more broadly than it had been before, that is someone who, as a first step to a long road of recovery, should come to a hospital and get some hospital care and get stabilized with medication.

I applaud him for his commitment to continuing to do that. As far as what happened during his gubernatorial administration, on the abandonment of state and city joint efforts to provide permanent supportive housing, which is, I think, another leg of this table that we've talked about, I do think it's unfortunate that the state and city kind of went their separate ways during the Cuomo administration, and we now have separate city and state programs to provide permanent supportive housing. I think there are synergies that are lost by not having that kind of collaboration, and I do hope that's something that we can get back to in the future.

Brian Lehrer: Do you have anything on any daylight that there may be between Cuomo's and Sliwa's positions on this?

Brian Stettin: Well, when I listen to that clip of Curtis and, look, he's someone I have a lot of respect for, I think he deeply cares about the population he's out there engaging with. I salute him for that, but I do think there is a misunderstanding on his part on what we can actually do under the law to get people off the street. There are lots of heartbreaking cases, people who are choosing to remain on the street in a city where there is a right to shelter.

I don't mean to suggest in any way that anyone chooses to be homeless, but when you're unsheltered in a city where we're under a court decree to provide shelter to every person, there is some element of choice in a person being out there. It's easy to assume that that's entirely attributable to severe mental illness. I think that we sometimes underplay, especially when we see people behaving erratically and assume they must be mentally ill, we underplay the role that substance use disorder, addiction, also plays in this kind of large, intractable problem.

We don't have a mechanism right now to provide involuntary treatment to people who are suffering purely from addiction. Sometimes we bring people to the hospital who are behaving erratically and appear mentally ill, so they meet the criteria for removal, but when we have them during that 72-hour hold to evaluate their condition and decide whether to admit them to the hospital, we find that they metabolize the substance they had taken.

Very often, there is no underlying severe mental illness, so there's no authority to hold that person in the hospital. The public sees that Person back out on the street, and maybe the police officer who brought them in sees them out there again the next day. I understand that's demoralizing, but I think there needs to be more recognition of the limitations of what we can do. There shouldn't be an assumption that everyone we see out there is suffering from severe mental illness, and then that removal is a wholesale solution.

Brian Lehrer: Well, for those people you just described, is there a solution? Is there another kind of involuntary removal from the streets or given civil liberties, not really?

Brian Stettin: Well, 37 states have laws on the books that make it possible, under different circumstances, the laws vary, to involuntarily hospitalize somebody for treatment for addiction, and New York is not one of them, so that's not a tool we have in our toolbox. It's something that Mayor Adams has proposed we should bring to New York. These heartbreaking situations where we're letting people walk out of the hospital because we don't have legal grounds to hold them currently, yet we know they remain a danger to themselves or others, I think we could make progress in many of those cases if we had that additional tool.

I want to say I think it should be more limited than it is. If you look at what's on the books in a lot of states and some of the research on the efficacy of it, it's not impressive. It's not used particularly often or particularly well in other states. I think there's an opportunity in New York to do something a little bit different with involuntary removal and involuntary admission for substance use disorder.

I would limit it to situations where we're talking about someone with a very severe addiction whose life is literally at stake if we continue to let them remain on the street. I think ultimately that the treatment is going to have to be voluntary, that what's going to actually allow them to recover from their addiction and live stably in the community is going to have to be an internal decision that "I can't live this way anymore."

The problem we face is that when we're kind of making an offer to people who come in on these removals now who turn out not to have mental illness, and we ask them, "Would you like to get involved in some of these terrific programs we have and some of these great medications we have to deal with your addiction?" the person's not even really hearing the question because they've been in that ER for a day or two.

They're in physical pain because of withdrawal. We would like a law that would let us to just get the person to the other side of that withdrawal to hold them for a short-term detox in order to make a decision about what they want to do with the rest of their life.

Brian Lehrer: Is it your understanding that any of the remaining candidates are proposing anything like that?

Brian Stettin: Haven't heard that from any of the remaining candidates.

Brian Lehrer: Michael, anything on that either as an option that you like or dislike, or with respect to candidates?

Michael Hogan: I agree with what Brian has said, that it should be a tool that is available. I agree that it should be used in a relatively limited fashion. The problem is in a way an analog to the problem of serious mental illness, except it's worse in that investment in, and the adequacy of care for people with substance misuse problems, it's much worse than it is in serious mental illness, where it's already bad, but there should be some way to get people from on the edge of death into care.

I don't really know. I would not be surprised if none of the candidates had talked about this explicitly because it's a less developed issue, even though it's-- I don't know what the numbers are, but I'm going to guess that concomitant substance misuse is a problem for the vast majority of people who are primarily thought to have or to be disabled-

Brian Lehrer: Interesting.

Michael Hogan: -or incapacitated from a serious mental illness problem.

Brian Lehrer: The two of you kind of agree on that estimate, and yet from what I've read, none of the candidates are saying, "Prioritize involuntary removal for drug addiction and behavior stemming from drug addiction as opposed to targeting mental illness per se." Let's start with you just--

Brian Stettin: Yes. To be clear, Brian, that would take a change in state law, so what they'd have to call for is an amendment of the state law. You can't do it under current law.

Brian Lehrer: It's our 30 Issues in 30 Days election series, Day 7 with Issue 7. When is involuntary hospitalization good or necessary for people, as we've been framing it, seeming to be a threat to themselves or others in New York City on the basis of severe mental illness? You've heard both of our guests bring in drug addiction to this as well. Mostly, we've been talking about Cuomo and Curtis Sliwa.

We're going to talk more in detail about Zohran Mamdani's alternative proposal to create a Department of Community Safety and how different that might actually be. We'll ask our guests if they're familiar with the Denver model that Mamdani cited in the clip we played as something that New York might follow. We'll go to some of your calls and texts on this. Stay with us.

[MUSIC]

Brian Lehrer: Brian Lehrer on WNYC. Our 30 Issues in 30 Days election series, Day 7, with Issue 7, when is involuntary hospitalization good or necessary for people seeming to be a threat to themselves or others in New York City, based primarily on severe mental illness? Our guests, contrasting their views, are Brian Stettin, currently a senior advisor on severe mental illness for Mayor Adams, and Michael Hogan, who was the New York State Commissioner of Mental Health from 2007 to 2012.

He is now a consultant at his company, Hogan Health Solutions. We'll get into the Mamdani proposals in a second, but so many people are calling and texting. Let me get a few voices on here. Michael in Red Hook, you're on WNYC. Hello, Michael.

Michael: Hi. How are you doing today?

Brian Lehrer: Good. You have some experience in this field, I see.

Michael: Yes, I have a combination of lived experience. I've both been chronically homeless, also in long-term recovery, also a licensed clinician, also a certified peer, so I've worked at every different level, both inpatient, outpatient, street outreach work. I've worked with the homeless. I've worked in family shelters. I've worked in community-based care, and I've worked in inpatient residential settings, so I have a very wide range of experience to draw from.

There are a number of things that were discussed very casually that give me a lot of concern for the distanced removal of people who are key decision makers from the people whose lived experience ought to be informing the policies that affect them. I would say that it would not be a very contested conversation with regard to involuntary commitment when it comes to, especially, people with substance use disorders.

There's a few things that I want to point out. One is that we don't have sufficient services and resources for the people that are already seeking treatment voluntarily. One of the reasons for that is that the substance use treatment system does not have an adequate ability to treat people who are dually diagnosed. Because we have an overdose crisis, what's happened silently alongside of that is another crisis of severe and persistent mental health that results from anoxic brain injury.

People who are overdosing are not being screened, and there's nowhere to get them tested. There's a severe shortage of neuropsychological testing centers that could do adequate testing that would be necessary to provide them with reasonable accommodations and support to be successful in the treatment environment. We do not have long-term residential settings for people with severe persistent dual diagnosis, which a lot of our patient populations are, so even though we'll send them in and out of hospitals, there is no long-term support solution, so we see serial readmissions even amongst people who are already seeking treatment voluntarily.

Brian Lehrer: Let me jump in here for time, but it sounds like you're seconding what one or both of the guests was saying before, that the people with a combination like you say of mental illness and drug addiction or just drug addiction driving them to their to their current states, there aren't the necessary supports for them and the law doesn't deal with them in particular as it provides an option for involuntary hospitalization for people seen to have mental illness per se. Michael, from your experience and everything you've been saying, caller, would you like to see a change in the law? Do you think that's needed to enable the kinds of things you're advocating?

Michael: Absolutely not. I think that the necessary protections of the law help to prevent the undermining of the very fabric of our Good Samaritan laws, so what ends up happening if people feel that they're going to be involuntarily committed in the event of like an overdose, which is a common crisis where we see people, if they feel their rights are going to be taken away, they will not call 911.

They will avoid service providers. They will not engage in services. They will avoid law enforcement detection, and it will undermine service engagement even amongst people that are voluntarily engaging in services, which creates a more hostile treatment environment [inaudible 00:36:15], who are there involuntarily are engaged in conflict with providers and undermining the treatment of people who are there in or who are there voluntarily.

Brian Lehrer: Got it. Very interesting. Thank you for your call. Jordan in Queens, you're on WNYC. Hi, Jordan.

Jordan: Hi Brian. Hi to Brian and Michael. Brian Stettin knows me. I am a peer, which is a person with lived experience, as the other Michael had described previously. I'm also the Director of Advocacy at a supportive housing provider in New York City. I am also kind of called the peers, not police girl, when we're talking about non-police mental health crisis response, but the thing that I really wanted to bring up is talking about basic needs and the new provision that was added to expand the law, and how it's really problematic.

Brian Stettin already knows this story, but basically, when I started my career, I met a woman who was unsheltered, who easily could have been brought up in the new expanded AOT Kendra's Law. She reeked of urine and feces. When you talk to her, though, she was doing that as a means of self-protection. She thought, "The dirtier and smellier I am, the less likely I will be sexually assaulted as I sleep."

I think about that woman every day as I work, because what AOT does and as Michael described previously, the previous caller, it strips people of their expertise. I think a big part of this conversation that I wish had more highlight in this discussion is the need for peers and connecting with people in crisis, genuinely, about that lived experience. I know that there are disagreements about people's cognizance of their own mental health, but I think that we're giving people the short end of the stick. We also are just so uncomfortable with the extreme realities of poverty, i.e., Jordan Neely, that we'd rather turn away and have it shuffled along.

Brian Lehrer: It's interesting that you mentioned peers because one of the things that Mamdani mentioned in the clip, and because it's been so long since the beginning of the segment and we really haven't addressed it yet, I'm going to replay it in a minute, that he says would be in this Department of Community Safety team approach is a peer would be one of the three people who were sent out. You use the word "peer," so would I be right in assuming that you kind of like the Mamdani proposal? Jordan?

Jordan: Yes. I can't comment on specific proposals as a staff person of a nonprofit, but what I can say is, as an organization, we are committed to pushing policy proposals that really enable choice and utilize peer expertise.

Brian Lehrer: Thank you for your call. We really appreciate it. All right, since it's been over a half hour and we really haven't addressed the Mamdani difference from Sliwa and Cuomo very much yet, and we want to, of course, do that justice, I'm going to replay the clip of Mamdani talking about what he wants to create that he calls a Department of Community Safety. This is Mamdani at a Columbia University Journalism School forum hosted by the public safety-oriented journal Vital City. He was asked what would happen under that plan when the department becomes aware of a person in an acute or seemingly ongoing, either one, mental health crisis.

Zohran Mamdani: You would have teams of three. In those teams, you would have an EMT. You would have a peer, because we've also seen time and time again that having a peer present in these interactions is critically important. I'll give you an example of how this could work. In Denver, they had a STAR program. This is a program that focuses on low-level crime. In the neighborhoods where they focused, that crime went down by 34%.

Over the period of a number of years, they had 12,000 clinical interactions. Of those, only 3% required a medical hold. I say this because oftentimes in this conversation around subway safety, in the conversation around mental health, there also comes a question of involuntary commitment. What I have said time and again is, it's outcomes, it's evidence, and reading some of the research around involuntary commitment, not being fully convinced that this actually has the outcomes that we hope that it would in terms of remedying this, but saying that this would be a last resort. However, the first resort has to be actually engaging and interacting.

Brian Lehrer: Mamdani at that Columbia University Journalism School forum from Vital City. Brian Stettin, let me go to you on this. Since you work for Mayor Adams in this area, maybe you'd be the more likely to disagree with something in Mr. Mamdani's take. What's your reaction to that proposal, and are you familiar with the Denver program that he used as a model?

Brian Stettin: I am, and it's a good program. I don't think it's as different from what we do in New York as he may assume. Look, there is a place for the type of crisis response he's describing that doesn't involve police and doesn't involve even contemplation of taking somebody to a hospital. There are people who really simply need someone to talk to in a moment and to be connected to community-based providers as soon as.

We have a program, and we actually inherited it from the de Blasio administration, but it's something we've remained committed to called B-HEARD, which is absolutely about that. We want to maintain that kind of response for situations where it's appropriate. I think the problem is in assuming that to be a larger chunk of the total number of mental health calls that come into 911 over the course of the day than it actually is.

Now, if you look at the criteria for when we're making a decision to use B-HEARD rather than sending a police response, it's really not a whole lot different than those jurisdictions that are sometimes held up as models for this. New York City is a very different kind of place. When you're talking about somebody who is in acute psychiatric crisis and where there is a need to go to a hospital, there is a need to have a police officer on scene.

It's not to say that police should be taking the lead in the engagement or trying to convince the person to come to the hospital voluntarily. That's something that ought to be done by a clinician. Having a peer on site is never a bad thing, but to me, there's kind of a false choice that's been set up between an all-police response and a no-police response, right? There's a thing called co-response where we have clinicians in the lead, and we also have police officers on scene.

The police in that situation really fulfill two functions, right? They give the clinician a greater sense of safety and engaging with someone who frankly might be a little scary, and secondly, if a decision is made that person has to go to a hospital, you can't ask a nurse to get somebody onto an ambulance or to hold them there until the ambulance comes. That's a job for a police officer.

What we've tried to do in the Adams administration is increase the presence of co-response, particularly through some programs we've created in the subway system, where we're pairing clinicians with police and getting the best of both worlds. I hope that's not something that he has in mind to discard.

Brian Lehrer: Michael Hogan, for you, as maybe the more likely to think that more change is needed in the Mamdani style direction, you heard in the clip, he says involuntary hospitalization would only be a last resort, but they all say that, so how do you understand Mamdani's approach as being substantively different as opposed to just sounding less enthusiastic about using that last resort option?

Michael Hogan: Yes, right. Well, we'd have to talk more, and we have to go deeper to be really able to understand it. At a superficial level, my reaction is that his comments, Madame's comments, are compassionate and smart. That's my first reaction. My second reaction is that proposing a reorganization as a solution to a problem on the streets, it might be necessary, but it could be glib.

It's really hard work to make these things work effectively. Just as I said before, a proposal to expand involuntary commitment without doing the hard work to make good mental health care effective is like a Band-Aid on a tumor. Proposals for reorganization could be viewed similarly. They might be more performative than substantive. They might not be, but you've got to peel off the superficial, the comms layer of the work, and look at how substantive it is.

Brian Lehrer: Yes, comms.

Michael Hogan: Yes, I do think that the comments of both of your callers were really smart and illustrate the kind of depth that's required to make this stuff work.

Brian Lehrer: Would it be fair to say, though, from reading the Cuomo proposals, listening to Sliwa, and hearing the Mamdani clip and reading about him, that Mamdani is more likely to try to lean into creating all those external supports, and either Cuomo or Sliwa might be more likely to relatively more lean into the involuntary hospitalization if they were mayor?

Michael Hogan: Yes, it kind of sounds like that, and then there's the question of how much of that you can do as mayor when the state rather plays such a substantial role when Medicaid is used to finance most of this, and Medicaid is a little bit under assault, but I wouldn't disagree with your characterization of this. I'd also just say, not to throw a monkey wrench into this, that being involuntarily committed is not a walk in the park.

Without an assurance of the follow-up care that's needed, and we don't have an assurance so far in any of these proposals, we have proposals to do more and establish new programs and so on, but without an assurance of good care, it's unlikely to be effective. As a matter of fact, there's a recent study by the Federal Reserve Bank that looked at involuntary commitment and for people for whom it might have been a questionable decision and found out that outcomes were worse for people that were involuntarily committed, so none of these are simple solutions.

Brian Lehrer: That is Issue 7 in our 30 Issues in 30 Days election series on when involuntary hospitalization is a good idea. We thank Michael Hogan, who was just speaking, who was the New York State Commissioner of Mental Health from 2007 to 2012. He is now a consultant at his company, Hogan Health Solutions, and Brian Stettin, currently a senior advisor on severe mental illness for the Mayor's Office. Thank you both very much for engaging.

Michael Hogan: Thank you.

Brian Stettin: Sure. Thank you. Great to be with you.

 

Copyright © 2025 New York Public Radio. All rights reserved. Visit our website terms of use at www.wnyc.org for further information.

New York Public Radio transcripts are created on a rush deadline, often by contractors. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of New York Public Radio’s programming is the audio record.