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Brian Lehrer: Brian Lehrer on WNYC. Now we continue our midterm election series 30 Issues in 30 Days. This week we're doing segments on public health and preventing violent crime, today a topic where the two sometimes meet - mental health. The vast majority of people with mental illness, we should say, never commit a crime and are more likely to be victims of violence than perpetrators.

Think of all those stories of people in mental health crisis who are killed by the police, and the efforts now to send unarmed health professionals trained in de-escalation in response to many mental health crisis calls. High-profile incidents, like the person who allegedly pushed Michelle Go to her death on the subway tracks, or the Iraq war vet who allegedly attacked gubernatorial candidate Lee Zeldin with a pointed object at an upstate campaign appearance, Zeldin said the attacks seem non-political, rather likely linked to a mental health condition.

Incidents like those link the issues of violence and mental health in the public's mind, as do the people in crisis who are killed. Mental health is also the fallback cause of gun violence for politicians on the right who don't want gun laws. The historic bipartisan gun law passed by Congress this year, the first in 30 years, includes both some limits on guns and preventive mental health funding.

Then there's the mental health impact of the COVID pandemic among adults. More opioid use, more anxiety, and other effects among children. The effects of pandemic isolation or pandemic grief. Pandemic aside, the traumatic impact of poverty and racism and other things had already led to an increase in trauma-based education, as they call it. Trauma-based education in public schools.

As if that isn't enough, the crisis of mental health and the crisis of homelessness, especially street homelessness, are linked for too many people. We've talked recently on the show, and there was a New York Times editorial board essay recently on the failure to provide enough housing with supportive mental health services after the big deinstitutionalization wave of recent decades that allowed many more people with recurring mental illness issues to live in society, not locked away in psychiatric hospitals.

New York's Kendra's Law is about court-ordered outpatient treatment for certain people who have resisted help and have a history of violence or incarceration or threats. It was expanded in the New York State budget this year to have the resources to include more people, but over the objection of civil libertarians who don't like the idea of forcing people into treatment even as outpatients.

The budget also included money for a thousand more inpatient psychiatric beds in the state and 500 more supportive housing units that include mental health services. All that said, neither the Hochul nor Zeldin campaign websites mention mental health as a priority. 30 Issues and 30 Days, Issue 12, is there a Democratic and Republican way to address mental health, or is there just more of it or less depending on the politics of the moment?

With us now, the New York City Health and Mental Hygiene Commissioner, Dr. Ashwin Vasan, appointed by Mayor Adams partly because he used to run Fountain House, which provides services to people with mental illness. He was also a mental health policy advisor to the Pete Buttigieg presidential campaign in the 2020 primaries, and later to the Biden campaign in the general election. Dr. Vasan, we always appreciate how much you come on the show and talk about public health. Welcome back to WNYC.

Dr. Vasan: Thanks for having me, Brian. Always a pleasure to be here.

Brian Lehrer: You've been in mental health leadership before the pandemic, as I just mentioned, and since it began. How would you begin to describe what the pandemic has changed?

Dr. Vasan: Well, I think you did a pretty good job. You gave a really sweeping overview of the state of mental health and the challenges we face in our society, many that predate the pandemic and some of which has certainly been exacerbated by the pandemic. I would just add also that our rising overdose crisis has in part a component that is linked very clearly to underlying untreated or undertreated mental health issues. We're really up against it.

I think what The New York Times editorial does really nicely is talk about the fact that we are reaping the failure to invest in a real community mental health system basically since the 1960s. John Kennedy had a vision. He had a goal of really deinstitutionalizing our mental health asylums, and in its place rebuilding a robust system of healthcare, of social connection and community, and housing that could keep people who are most impacted by mental illness connected and living in the community in safe and stable ways.

We've failed to really invest in that at scale, and I think a lot of what we're facing, especially through the strain of the pandemic, is revealing the cracks in that system and frankly the absence of a system. I hope that we're at a moment where we can have a real conversation about how do we invest in mental health infrastructure and what are the components of that?

Brian Lehrer: As I mentioned in the intro, the new New York State budget this year includes more money for a thousand more inpatient beds and 500 more supportive housing units, which is, I think, what you were mostly just referring to. That kind of supportive housing for people with mental health issues. 500 units, is that a drop in the bucket?

Dr. Vasan: Certainly we're very pleased by that expansion, but we need much more. Just to be clear, housing is one component of this, but community and social connection is really essential. You can have someone who's stable on medications and stably housed who over time remains or becomes deeply socially isolated. It is in fact social isolation that is a harbinger of a crisis. Often we see people who are deeply socially isolated who become detached, who become increasingly unable to assess their own needs, meet their own needs, or have insight into their own needs. Those are the folks who most acutely need our help.

Housing is one component of it, but the program I ran, Fountain House, before coming into city government was really built first on community and social connection, with housing as one component of that along with healthcare. Really it's about those relationships, which not only serve as an anchor in the community, a way to buttress your life. Many people living with serious mental illness - there are over 14 million in the United States - have that support through their families.

For those who don't, having a place and a community that can not only serve to anchor your life but also serve as that early warning system when you start falling off your meds or you're behaving differently or you fall out of care, that's really what we're looking at here. Because we don't want our mental health policy to be driven only by acute events or tragedies or the public's mindset of what it means to have severe mental illness and the intersection of homelessness. There are so many other components to this, and it starts by building real social and community health and other forms of infrastructure that really haven't been invested in since the closure of the asylums.

Brian Lehrer: Listeners, we can take your calls here on our 30 Issues in 30 Days, Issue 12: Is there a Democratic and Republican way to address mental health issues? You don't have to call with a partisan comment. You could call with just what you would like to see more of from government based on your experience or that of people you know with respect to mental health services. 212-433-WNYC, 212-433-9692.

There aren't a lot of people who answer public opinion polls, political surveys by saying mental health is my number one issue. Obviously, we talk about abortion rights, we talk about crime, we talk about democracy. These are things that come up in the polls. We talk about inflation, but people care deeply about mental health services. Everybody knows somebody with mental health issues that are somewhat serious even if you don't have them yourself.

What would you like to see in terms of availability of services, in terms of government policy on any level in this area that maybe you've seen a lack of because of your experience, or who would you like to praise for what they are doing? 212-433-WNYC, 212-433-9692, or tweet @BrianLehrer for the New York City Health and Mental Hygiene Commissioner, Dr. Ashwin Vasan, who used to run Fountain House.

Dr. Vasan, I mentioned the bipartisan gun law passed by Congress this year, which includes funding for certain mental health programs. These include early intervention program for kids, showing signs of distress in schools, more community behavioral clinics, community-based clinics, and other things. I wonder if that federal law really addresses just what you were talking about a minute ago. Not just housing and not just intervention in extreme situations, but these ongoing opportunities for social connectedness that might prevent things.

Dr. Vasan: I think that's right. You're talking essentially about prevention and you're talking about public health, which is rooted in prevention. We don't want our public policy designed only around crisis, but rather what are the things we need to build in its place to prevent crisis from happening in the first place? That's a welcome investment. It's tragic that it takes gun violence and certainly the tragedy in Uvalde, Texas to get us working together.

You alluded to it in your comments just now. This is actually a bipartisan issue. I think the right [inaudible 00:11:18]. The left might be coming at it from different angles, but I think everyone can see the solution in plain sight. Mental healthcare is just far too hard to access for everyone. Even people of means and privilege report stories of struggles to connect their children or connect themselves into care. Even people with commercial insurance report networks that are already filled or networks that don't really exist. In-network providers that don't really exist. I know that the Department of Labor and others are doing work to [sound cut]-

Brian Lehrer: I think we might have lost--

Dr. Vasan: -to make sure our insurance is amending those networks. We have a lot of work to do, and it's in investment, and some of that will live inside of healthcare. The expansion of psychiatric beds is a good thing. We need to create a much bigger and broader workforce pipeline for psychiatrists, psychologists, social workers, many of whom are now incented to work in private practice if they even come into the profession at all.

Then, of course, we need much more community mental health infrastructure. What does that mean? That means clinics that are integrated with primary care, so integrated behavioral health and primary care clinics, and more rehabilitative programs, the kinds that I described as Fountain House, really building that social infrastructure and social connection.

There's really three pillars of the stool, three legs of the stool, that everyone needs at a very basic minimum in order to be stable and live with the mental illness. That's healthcare, it's a home, and it's a community. If we can start to really ensure those three things, guarantee those three things, we're going to be in a much stronger position to deal with our mental health crisis.

You also mentioned kits. I think this is where a slightly different approach is going to have to be taken, which is let's go to the places where kids are spending the most time and really make sure that those are places where we can identify, screen, and even connect children into the care that they need. I'm speaking specifically of schools, I'm speaking specifically of working directly with parents and families in the household.

Of course, after-school programs, school sports, anywhere kids are congregating and spending time should be places where we can identify whether they're having trouble, whether they're experiencing emotional distress, and what gets them connected into the kinds of supports they need. It may not be even healthcare that they need, but it might be just talking to a supportive network of peers or other services. Right now we often catch these issues too late or we misdiagnose them as academic or behavioral trouble, which are really lagging indicators of an underlying emotional or mental health issue.

Finally, we have to deal with trauma, and we have to really ensure that our schools and our other touchpoints for kids are trauma-informed and people are adept at anyone. Whether you're a teacher, an administrator or a nurse or a health provider, adept at really understanding the impacts of trauma on children's well-being and their behavior as a way to really catch these issues early and prevent them from devolving or evolving serious and chronic forms of mental illness as adults.

Brian Lehrer: Let me just mention, so our listeners know that they're not imagining things, that Dr. Vasan's line is a little bit shaky. You've heard it drop out a little bit, you've heard it slow down his voice a little bit. We're going to try to fix that, Dr. Vasan, as we go to a phone call. Susan in Nyack, you're on WNYC. Hi, Susan. Thank you for calling in.

Susan: Hi, good morning. Thank you for taking my call. Ironically, the good doctor there was repeating what I had just said to the young lady on the phone. I have three family members with mental illness. Forgive me, I'm just getting over COVID, so my voice is a little shaky myself.

Brian Lehrer: I'm Sorry.

Susan: They suffer from mental illness; my sister, my-- Thank you. My entire life. What I would say was there's very little funding for people with mental health issues. There's not enough housing. There's not enough support housing. The social workers are overburdened. The cases that they have, they have trouble keeping track of because there are just too many. I am someone who's advocated for my sisters. My folks passed; they used to look after them. The situation is impossible sometimes to get them the help that they need. I've been trying to get them housing for like four years - my sisters - and had to settle on a different kind of housing, and I'm able to get housing for my niece.

There are no truly rehabilitative programs in the county where they live, so I feel somehow more money needs to be spent on the mental health crisis. These are people with many years of disabilities, not just from distress and the trauma that we all just went through, but that have lived with this most of their adult lives. It starts there.

Brian Lehrer: What do the people there tell you when you try to get some kind of supportive housing for your sisters? When you apply, I guess, to state programs, is that it? Is it, "Yes, they qualify. We just don't have the beds," or how does that go?

Susan: Really, my folks passed several years ago, and I myself have health issues and more since I've been looking after them because I'm not running a group home. I'm a person with children in my own life. From the very beginning, I was told there was no housing. They would have to be homeless. They would have to be homeless, and even then there would not be any housing. I was told that by everybody, by their therapist, by the social worker. They had a case manager. By the way, I had tried to create a system for them in the family home that we own. I had a social worker for them and a home care nurse for them.

It took me a long time to create this support system for them. As far as housing, because we were having to sell the family house, I was just told repeatedly that there was nothing. Then I started speaking to the behavioral mental health nurse who knew them well and said there was some housing, and said furthermore she would make a call for me to the head of the whole housing system, which I also did myself. I went right to the top.

Some housing was available for them but then it was quickly given to someone else. I was really told it was just not true basically and relied on what the professional people were telling me so that I went through my life saving keeping them in the house that they were in to pay their utilities. Fortunately, we're able to deal with that. There was another family house to sell to pay us back, but because I cared about them and didn't want them on the street. Even with someone who has been around my whole life and somewhat educated, the system is, I'm sorry to stay, broken I feel.

My niece is another person who's tried to get help through the system and gets pushed around, and signed up for what's called a single point of access housing through the state and was offered housing then it was declined four times, and then they just dropped her.

Brian Lehrer: Woe. Susan, thank you so much for sharing what must have been a difficult story for you to tell. We really appreciate your calling and sharing it because people can learn from that. Dr. Vasan, I think as we were getting your line reconnected you didn't hear the beginning of it, but I think you probably heard enough to get the idea and to have something to say about what Susan's story and frustrations might be emblematic of systemically.

Dr. Vasan: Yes. Susan, thank you so much for sharing the story. Your story is so familiar to me and it's tragically repeated all too often. I think it's a generous term to call what we currently have a system. It is really a patchwork of solutions that have been created over time, largely in response to some of the moment we're in, which is anxiety, worry, fear, and often linked to threats of violence or concerns around homelessness. Which is one entry point, certainly for a discussion around mental health, but we need to take a step back and think about what do all human beings really need and what do people who struggle to take care of themselves do to mental illness need in terms of support, and then really invest in it.

I'm so sorry you've struggled so much, Susan, because this is really a patchwork. The things that we're trying to do at the city are to balance the acute need, which is to say what are the things we can do to support the exceedingly small number of people in the bigger scheme of things who might need assisted care, whether that's expansion of certain laws or reduction of administrative barriers to get people into care or into supportive housing. While also making investments into the rehabilitative social and connective infrastructure that people need, whether it's community-based healthcare and expansion of social work and mental health providers, or expansion of models like Fountain House and clubhouses, which are really intended to provide long-term psychosocial and rehabilitative support so people can learn to live with a chronic mental health condition.

That's our attempt certainly at the city, but it's going to require reform at the state and federal levels too, as well as pretty dramatic investment.

Brian Lehrer: This is WNYC-FM, HD, and AM, New York; WNJT-FM 88.1, Trenton; WNJP 88.5, Sussex; WNJY 89.3, Netcong; and WNJO 90.3, Toms River. We are New York and New Jersey Public Radio and live streaming @wnyc.org. Few minutes left in our 30 Issues and 30 Days election series, Issue 12, for today, mental health as an issue in the midterms. Is there a Democratic and Republican way to improve mental health services? We'll take one more call. Donna in Westchester, you're on WNYC with New York City Health and Mental Hygiene Commissioner, Dr. Ashwin Vasan. Hi, Donna.

Donna: Hi there. How are you doing?

Brian Lehrer: Good. What you got?

Donna: Good. I have the bipartisan issue is education, and in 2018, New York became the first state to require mental health literacy education in schools, but the problem is it's not happening. Many states have since passed laws, and it's great in terms of legislative headlines. We need to actually implement that in schools because so many of the legislative laws that are passed have funding to do with let's hire more school psychologists, but we don't have more school psychologists. They're not out there.

We need to begin Tier 1 education across K-12. Secretary of Education Cardona, in October of last year, suggested that every K-12 school should be implementing both SEL and mental health literacy, but it's just not happening.

Brian Lehrer: SEL being social and emotional learning. Donna, thank you very much. Response to that now that you've been health commissioner for most of a year in New York City? Are you familiar with that state law that she says was passed but is not resulting in more school psychologists, for example? Do you work with the Schools Chancellor Banks on getting more mental health literacy, social-emotional learning, trauma-based education into the schools after the pandemic pause?

Dr. Vasan: Yes, absolutely. It's an enormous point. I alluded to it earlier how bringing mental health services as well as mental health screenings and early intervention is essential in our schools. I'm certainly familiar with the state law, but I'm working very closely with Chancellor Banks on this very issue. I think the caller rightly identified that there isn't a workforce of psychologists and psychiatrists willing to come into school necessarily off the shelf. What we need to do is really strengthen the role of school nurses, really bolster that workforce. They are often the front lines of identifying health issues in our children. They played an enormous role in COVID and keeping our schools open.

There's no reason why they can't be further trained and empowered to provide mental health screenings and social and emotional learning and early identification. Teachers, administrators, bringing them in. I know the chancellor shares that goal as well. Every adult in the building needs to be able to identify when a child is in distress or having issues that might be showing up in academic performance or behavior. That's certainly our commitment.

Brian Lehrer: I know you got to go in a minute, but just to ask you one political question. When there's a mass shooting, often Democrats yell guns and Republicans yell mental health. You were the mental health policy advisor to the Pete Buttigieg campaign, then the Biden campaign in 2020. I'm just curious what, looking back, you were up against in this respect, especially in the general election. Is there a Democratic and Republican way to approach mental health policy at the federal level?

Dr. Vasan: Look, I think number one, I was certainly one of many voices in the room, but I think we have to focus on what good looks like. What do we want out of this world and what do we want out of this system? I think there's so much to agree on, which is why you actually are seeing mental health bills. There's a bill called S.1902, which is around standardizing our mental health crisis system. That's John Cornyn and Senator Cortez Masto from Nevada. Strange bedfellows you might think.

Brian Lehrer: Democrat and Republican, yet.

Dr. Vasan: Correct. People who can think and offer up a rational vision for the future of what a good mental health system might look like. I think this is my larger point that I've said a few times. It's just we cannot design good long-term policy necessarily around moving from crisis to crisis and from tragedy to tragedy. We've got to actually have a long-term view to building the kind of mental health infrastructure that John Kennedy envisioned, and that we never really got to. President Carter tried to revitalize it and it was shut down by President Reagan after he was elected out of office.

Now is the time. If there was ever a time, it's now. I think there's a real moment of public interest, of bipartisan interest. The question is where are we going to see leadership to bring people around the table to design something better for all Americans? I'm hopeful that the time is now

Brian Lehrer: New York City Health and Mental Hygiene Commissioner, Dr. Ashwin Vasan. Thanks so much. We really appreciate this.

Dr. Vasan: Thank you as always.

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