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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning again, everyone. The latest murder to make headline news in New York City may have several things in common with the last one. Christina Lee, who was killed in Chinatown on Sunday when a man followed her into her building, and Michelle Go, the woman pushed onto the tracks at Times Square last month, were both allegedly killed by men who may have had serious mental health issues. We know that to be the case in the Michelle Go murder.

It is seeming it may well be the case for the man charged with killing Christina Lee. Of course, both victims were Asian-American women. We talked about that aspect on yesterday's show about hate crimes. Today we'll focus on the mental health of alleged perpetrators such as these and why they fall through the cracks until they sum to do the worst possible thing. In fact, as you'll hear, one of our guests doesn't even like the term "fall through the cracks".

This is a New York City issue. This is an issue in cities across the country. With me now, our New York Times Poverty and Social Services correspondent, Andy Newman, who has a story called Decades Adrift in a Broken System, Then Charged with a Death on the Tracks, and Dr. Anthony Carino, MD, Director of Psychiatry at CUCS/Janian Medical Care, a health care program for people impacted by homelessness. Andy and Dr. Carino, thank you for coming on, and welcome to WNYC today.

Andy Newman: Thank you, Brian.

Dr. Anthony Carino: Thanks, Brian. Good to be here.

Brian Lehrer: Andy, the alleged killer of Michelle Go is a man named Martial Simon. Who is he?

Andy Newman: Martial Simon is a guy who he's 61 years old. He was born in Haiti. His family moved to New Jersey when he was a teenager. He led a pretty normal life up until he was in his 30s. He drove a cab, he worked in parking lots, he managed parking lots. Then in his early 30s, according to his sister, he started becoming delusional and was eventually diagnosed with schizophrenia. Since the late '90s, he seems to have just been bouncing around the city, homeless pretty much all of the time, except for one year when he went to live with his sister.

In and out of hospitals, in and out of jails, being found unfit to stand trial, which means they send you to a mental institution, getting discharged from mental institutions but without any kind of coordinated care plan, so he just reverts to bouncing around. We talked to somebody, another homeless guy who had run into him many, many times over the years and actually become friends with him, and said that Martial Simon used to complain that the doctors were discharging him from the hospital before he could be stable, that he kept running out of his antipsychotic medicines.

Just from trying to piece together bits of his life, we came away with a sense that he was a guy who was just basically adrift, just couldn't really take care of himself well, but no one seemed to be stepping up to really say, "Hey, this guy is just repeatedly getting back on the street, he's obviously in very poor health, he's out of reach of his family." Someone should have been helping him during this time. He did get very short-term help if he was in a hospital for a few days or a few weeks.

There are a lot of mentally ill people out there who just get treated like hot potatoes by the system where if you're in a shelter, they can't handle you, so they ask to send you to a hospital. The hospitals don't want to keep people anymore. There's just no-- It's a very uncoordinated system, if you want even to call it a system.

Brian Lehrer: Your article describes Martial Simon's life as an endless circuit of hospitals and jails, outpatient psychiatric programs, and the streets. Dr. Carino, I want to bring you in on an aspect of that because Andy's article says that Simon Martial's ire was sometimes directed at hospitals that were discharging him before he believed he was well enough to leave on his own. That's the opposite of what many people might assume is the more typical day dynamic, right? Everyone wants to be freed from psychiatric hospitalization, and the system locks them in. What's the Martial Simon's story in that respect, and what does it exemplify for others?

Dr. Anthony Carino: I think, Brian, that that aspect of the story, it really has to do with access to psychiatric care and services in the community, and really accessible psychiatric care. Really, an approach that we found to be effective is to get out there with teams into the community and really offer and engage individuals with a trusting relationship, a psychiatrist, talk therapy, and medications, and really couple that with access to housing and benefits. Oftentimes, patients will respond to that over time. When psychiatric care and treatment is accessible and truly accessible, people really respond and the risk lowers.

Brian Lehrer: Andy, you even report that Martial Simon was released from a hospital in 2017 despite saying he thought it was only a matter of time until he would push a woman onto the subway tracks, according to a source who saw some of his medical records. It was that specific?

Andy Newman: It was. Yes, it was completely that specific. This advocate for homeless people who I talked to had been contacted by somebody who was looking through Simon's records. The psychiatrist writes in his discharge summary, this is the psychiatrist who's preparing to discharge him who presumably is trying to make a record to cover himself. The psychiatrist writes that Martial Simon told him, "It's just a matter of time before I push a woman to the train tracks." That was in 2017.

Of course, it's very easy hindsight is 2020 and maybe people say things like that all the time. You would think that if someone has a history of hospitalizations of severe mental illness, even if they don't have a history of pushing people to the train tracks, you would think, and Maybe Dr. Carino can speak to this, that a psychiatric hospital wouldn't be so quick to discharge them.

Brian Lehrer: Dr. Carino, if a patient said that to you, what would you do, or what do you hope you would do as the right thing if you were working in an inpatient facility?

Dr. Anthony Carino: I can't speak to the specific case and don't really know specifics around the case, but I do think that in terms of our approach, and my approach is that if people express risk, and there is significant risk of violence to selves or others, then the plan would be to work towards hospitalization. In particular, that's swiftly coordinated from the community. With regard to just general risk and risk factors, I do think that there are interventions that can decrease risk, and the majority of individuals with mental health conditions are not violent and can thrive.

Even people with homelessness and mental health conditions can thrive with outpatient community-based care. The challenge is that, for some individuals, they do have elevated risk for a period of time and oftentimes involuntary treatment is indicated at that point. I think that what we found is that the overall risk can really improve if people have access to things like permanent supportive housing and psychiatric care.

Brian Lehrer: Dr. Carino, as a follow-up, New York State's Kendra's Law makes it possible for involuntary hospitalization for people deemed a danger to themselves or others. Does it not get applied often enough by judges, in your opinion?

Dr. Anthony Carino: Yes, it's a good question. Kendra's Law is assisted outpatient treatment. It's an involuntary court-mandated treatment for people in the community. Majority of people do accept and can accept accessible care voluntarily, but-- [crosstalk]

Brian Lehrer: It's in the community, it's not involuntary hospitalization, to correct myself?

Dr. Anthony Carino: Correct. That's correct. For certain individuals that are at higher risk, there can be an involuntary outpatient order or a court-mandated order for treatment. What we found is for some individuals for a period of time AOT-assisted outpatient treatment can reduce risk. In particular, there are studies to show that AOT can lead to a 63% reduction in episodes of homelessness, 66% reduction in hospitalizations, and importantly, 73% reduction in incarceration. Assisted outpatient treatment can be helpful.

It also should be applied judiciously. One of the things that we've found is that in the last five years, AOT orders have decreased in New York City itself. One of the things that we've found is that it's challenging currently for community psychiatrists and therapists to apply for AOT from the community. That access to AOT-- We're told that people can access AOT once they're hospitalized. We depend on the hospitals to file an AOT order.

It's an important intervention that should be looked at and be something that could be more accessible to as a referral source for people that actually know the patients and are treating the patients in the community as opposed to having it only go through hospitals, who may not know the patient well and may not understand the arc of their treatment and their needs.

Brian Lehrer: Listeners, if you're just joining us, we're talking to New York Times Poverty and Social Services correspondent, Andy Newman, who has a story about Martial Simon the man who was admitted pushing Michelle Go onto the subway tracks at times square, a story called Decades Adrift in a Broken System, Then Charged with a Death on the Tracks, and Dr. Anthony Carino, MD, director of psychiatry at the social services organization called Center for Urban Community, their Janian Medical Care program, which is a healthcare program for people impacted by homelessness.

In particular, this is one of those segments where I haven't even given out the phone number, but this is such a big issue in our area right now as it is in cities around the country that the lines have filled up with callers before I even give out the phone number. Let's take a caller right now. Irene on Long Island, you're on WNYC. Hello, Irene.

Irene: Oh, my goodness. I am so thankful to have you take my call. We have a son who has had severe bipolar mania for about 12 years now. This is about the 12th year, started when he was 23. He did move some years ago about five years ago out to California. I rush out there anytime there's a problem. We have gotten him into an ACT program which is somewhat lower level AOT program out in California. He has a doctor there. He really admires and likes. He has people who come, actually, they'll deliver food to him if he needs it.

Most of the year, he's in good shape and he continues with his meds and he does go see the doctor. About once a year, he has a manic episode. Almost every year, it's a crisis and he has to be admitted into a hospital. This year, for the very first time, he tried to go to a hospital early on in the onset of the mania and he could not get in because he was not suicidal. It outrages me that with the doctors' cooperation and the patient's desire to try to halt something that's a crisis, that he cannot get in unless he is suicidal or dangerous or a threat to others.

Brian Lehrer: What's the reason that he was given as specifically as you know it?

Irene: The reason is because he was not suicidal or a danger. He was not a threat to others.

Brian Lehrer: Just as you said. Andy, do you want to take that? I mentioned in the intro another psychiatrist, not Dr. Carino but another psychiatrist, quoted in your article says, people do not fall through the cracks, as we often use that term, they are pushed through the cracks out the door into an abyss. I wonder what Irene's story about her son exemplifies and how it relates to your article if you think it does.

Andy Newman: It relates at least tangentially. Irene, I'm really sorry to hear that that happened to your son. It must be just so completely infuriating and frustrating and terrifying as a parent. The psychologist who I talked to who said people get pushed through the cracks, his name is Xavier Amador. He said that in his opinion, he's not a psychiatrist, he's a psychologist but he's been dealing with psychiatrists for a long time, that psychiatrists in this country only look to treat whatever an immediate problem is and not try to keep people stable over the long-term. As far as why Irene's son wouldn't even be admitted, I don't know what the laws are. If you're involuntarily being hospitalized, you need to be found a danger. f you are voluntarily attempting to get yourself hospitalized, I cannot picture why a hospital would turn you away. Maybe Dr. Carino can speak to that.

Dr. Anthony Carino: Irene, sorry that you had that experience. I think it sounds really frustrating and is frustrating and really important that he's gotten some good community-based care. I think if someone is--It's good that he's aware of his illness, of his symptoms and there's an act team or ACT team that's supporting him on it. I think that the hospitals do have limitations. I think in New York City, what we've seen is that the coordination between the hospitals and the community psychiatrists and treatment teams could really and should really improve where there's clear communication between the hospitals and the community treatment providers.

Brian Lehrer: Let me ask you this, Doctor. 50 years ago, there was a deinstitutionalization movement. There was the book and the movie One Flew Over the Cuckoo's Nest. There was the belief that many more mentally ill people than previously acknowledged could live outside of institutions. Was deinstitutionalization romanticized to the point where it went overboard, in your opinion?

Dr. Anthony Carino: I think what needed to happen is that the care and the supports and resources should have been transitioned. What happened is that as there was deinstitutionalization, there wasn't a reallocation of resources to the community, and we have a patchwork of support. I do think that there's a lot of community treatment that can be effective but also there needs to be improvement in the coordination and what inpatient psychiatric hospitalization may look like.

For example, there's a long-term psychiatric inpatient unit at Bellevue that works with people experiencing homelessness. The length of stay there is much longer than the four to six-day length of stay that many of the psychiatric inpatient hospitalizations have in the city. That inpatient stay is a higher quality and oftentimes, there's better coordination with outpatient providers, and leads to people to access housing and get on better psychiatric medication treatment and addiction treatment.

There needs to be a relook at what inpatient psychiatric care looks like, length of stay, and access to the psychiatric beds. There's also been a significant decrease in the number of psychiatric beds that are accessible with COVID, and we've seen a drop in the numbers, and units being reallocated towards COVID patients. That's left a series of problems in terms of accessing inpatient care for our patients.

I recently had a patient who had to go to a hospital 20 miles outside of the city instead of the hospital that was close to his family and him that he preferred. Our team had to coordinate very closely with that hospital. In a way, that was challenging if we hadn't been calling multiple times throughout the week and case conferencing frequently. There needs to be more access to longer-term, higher support, and actual inpatient services in New York City.

Brian Lehrer: Let's take another call. Derek in Manhattan, you're on WNYC. Hi, Derek.

Derek: Hi, thanks for taking a call. I'II try to be as brief as possible. I think the problem started when I was alerted to it in the early '80s maybe one or two. Reagan was in the office and one of his early task was to do-- what do you call it? Tax reduction. Where they pulled the money from one of the areas was psychiatric asylums, I think they were called. Long-term care facility for people with mental illness and it puts mentally ill people basically on the street. The states tried to rehab people in local community settings. I think there was Pataki back then, a little bit foggy, could have been big Cuomo, that if you failed, I remember because I was assaulted by a guy who was obviously not in his right mind. When I queried why this guy was on the street, that's what my research led me to.

My example is, there was a guy with a sword on the Staten Island Ferry trying to chop people up. He was subdued, they sent him to Bellevue. The story disappeared from the news for about a year and a half. I think they kept him in some kind of psychiatric thing. Then what wasn't reported was they actually released him. Because a couple of years later, the same guy with another sword showed up in St. Patrick's Cathedral, and try to chop up Cardinal O'Connor. Luckily, there was an off-duty detective during worship services that they got a hold of the situation. The guy was subdued again, he lived through it. What wasn't reported in the papers was that it was the same from the ferry three to four years earlier.

Brian Lehrer: Those are obviously more horrific incidents in those cases from the past, and the history that he talks about there, Andy, if I'm not mistaken, there was one of the New York Times colleagues, like 20 years ago, 20 years ago, I forget who the reporter was, who wrote a book, largely about exactly what Derek brings up: that after the deinstitutionalization of the '70s, there was supposed to be this funding for a large network of outpatient supported housing that never really got funded. Whether it's laid at the feet of Ronald Reagan and the Congress of that era, or at the state level, it never happened the way it was supposed to happen. Maybe we're living with the consequences to this day. Should we draw a line back that far?

Andy Newman: I don't really know too much about the history that goes back that far, though I do know, of course, that every time that something like this happens, there was some kind of government reaction where they say, "Oh, we're going to do this," or "We're going to do that," and they and they do some kind of piecemeal thing that doesn't quite help people. One of the things, there are so many pieces of this puzzle and so many things that are messed up.

Something that was supposed to have changed back in the '90s, there was a court decision in 1993 that required hospitals to do discharge planning with people with mental illness, and maybe Dr. Carino knows a little bit about this. It's called the Koskinas case. Now you see hospitals are not doing it or who are discharging people who are not ready to go back to the street but even more than that, they're discharging people without coordinating with the caregivers out in the community. To what Derek was talking about, I don't really know what happened in that case.

Brian Lehrer: We're talking with New York Times Poverty and Social Services correspondent, Andy Newman, who has a story about Martial Simon, the man who has admitted pushing Michelle Go to the subway tracks in Times Square, called Decades Adrift in a Broken System, Then Charged with a Death on the Tracks, and Dr. Anthony Carino, MD, Director of Psychiatry at the Center for Urban Community, Janian Medical Care program, a healthcare program for people impacted by homelessness.

Dr. Carino, I think it's really important to say in the segment that we're talking about these cases because they ended so tragically for other people and for the alleged perks to though they are still alive. The other side of this pendulum is the stigmatization of people experiencing homelessness as criminals and of people experiencing mental illness as criminals. Are you concerned about a policy backlash that would undo decades of work to destigmatize people who deserve to be destigmatized?

Dr. Anthony Carino: Yes, I think that it's important to remember that the majority of people experiencing homelessness are not violent and that individuals with psychiatric needs need respond to support and can respond to community-based services. Some of the things that we found is that patients that I've met who were disaffiliated on the church steps, on the sidewalks out there in the parks, over time, they'll respond to engagement to outreach. They'll build trust and support, and they'll come inside and accept permanent supportive housing when it's available.

Reallocating resources, having resources for the community is the way to prevent and decrease risk but also support people and having meaningful lives. My patients accept care and housing and support when it's accessible. We work with really great outreach workers, case managers, and teams that not only support the psychiatric treatment but also provide housing too, which makes a big difference for people because we're actually intervening on some of the actual social determinants that are impacting them an increase in risk.

I am concerned that there could be an overreaction or stigmatization and I've seen that allocating resources to the community is really, really valuable. Permanent Supportive Housing Works, teams like ACT that Irene mentioned, and Intensive Mobile Treatment teams, IMT teams in the city work and decrease the risk for people and provide access to care and treatment and support. Having access to those resources can really make a difference in people's lives.

Brian Lehrer: Let me take a caller who I think is going to amplify the premise of my last question. Cyrus in Brooklyn, you're on WNYC. Hello, Cyrus.

Cyrus: Hi, Brian. Longtime listener, first-time caller. I just wanted to commend the speakers for mentioning that last point. Stigma, as an inpatient psychiatrist in Brooklyn, who works in one of the city hospitals, is something that we try and work against every day. The discharge planning for some of these folks, as speakers mentioned, is extremely complex and the risk assessment is something that we always take very seriously. Unfortunately, people do say provocative things, even on the day of discharge.

I know this has happened to me personally with a number of patients over the years. One of the points that I wanted to make is that the vast majority of people that have persistent, either refractory illness or severe illness, are not violent people and they tend to be more on the receiving end of violence, street violence or institutionalized violence. I think that's just a point that is worth echoing and making again.

Brian Lehrer: Working in the system and in the way that you do, have you seen changes in either numbers or degrees or types of inpatient mental health patients who you're seeing during the pandemic?

Cyrus: That's a good point. I'm a relatively junior provider. I'm in my mid-30s. I work with colleagues that have been doing this a lot longer. Something that we've noticed is that folks that have been on the streets during a pandemic have been especially hit hard. There's even further isolation that's a result of that. On an inpatient unit, which is really nowadays, primarily for what you described earlier as acute stabilization, we have been trying to make an effort to work with administrators across various hospitals to get people into either adult homes, these aren't nursing homes, but more supportive housing. Also, into state hospital facilities where they can be receiving longer-term treatment. Those referrals have been up, at least on the units that I cover, and they're working.

Brian Lehrer: Thank you for your call. I really appreciate it. We're going to run out of time in a few minutes. Andy, your story is a local one in New York City about one killer in Times Square. Could this also be a national story or similar things happening in major cities everywhere in the US?

Andy Newman: I don't actually know enough to really give you a decent answer on that. Of course, I know that deinstitutionalization is a nationwide phenomenon, but I'm sorry, I don't really know the answer to your question.

Brian Lehrer: Dr. Carino, same question, if you know?

Dr. Anthony Carino: I think that there's been an increase in homelessness in psychiatric [inaudible 00:29:57] but I can't speak to that specific issue around risk. I did want to follow up with what Andy had shared in that the city has made some innovations that could be helpful, that are helpful. One is the crisis; it was called the support and connection centers, which are crisis stabilization beds for people, where they could potentially access crisis beds before going to the hospital if they don't require inpatient hospitalization, which could prevent a hospitalization or a criminal justice involvement.

We have two of those, they're primarily accessible through NYPD and a specific team. If there were more support and connection centers, crisis beds, that were accessible and psychiatrists in the community could refer people to those directly, it would decrease risk and help, decrease hospitalizations so that people could get crisis support before they might need hospitalization.

Brian Lehrer: I'll ask you as a closing question and invite Andy to weigh in too. Do you see the seeds of the needed response in mayor Adams' blueprint to end gun violence or other policies the new administration is advocating?

Dr. Anthony Carino: I think that he's named in his report that access to mental healthcare for people that are experiencing homelessness is important. That is important. I think that the things that we've seen that help that would benefit from scaling up for the city would be the increase in IMT teams, increase in supportive housing, and much better coordination between hospitals and those treatment providers that are providing care to people in need.

Brian Lehrer: Andy, the same question with certainly a lot of media focus, is there policy focus?

Andy Newman: One of the things that Adams was talking about during the campaign was increasing something called respite beds. I don't know if they're the same thing as crisis beds, but there were a similar thing. There are hospital beds for people who are not considered mentally ill enough to need to be hospitalized, but just need to get off the street for a while. That's a model that is widely credited with helping people get stable.

Adams has talked about that. He's talked about building more supportive housing, the big statistic that you always hear about supportive housing, which is housing that comes with onsite social services, is that for every person who qualifies for it-- I'm sorry. For every slot that exists, there are three or four people who qualify for it who can't get in. That's something that's definitely needed and Adams has talked about doing that. Creating supportive housing is very expensive, so there needs to be money allocated. Governor Hochul has talked about expanding supportive housing, and also about expanding Kendra's Law, which is another policy approach. Governor Hochul has talked about-- and also state Senator Diane Savino.

This is not Eric Adams, but this is just other policy fixes that have been discussed. State Senator Savino has proposed expanding Kendra's Law so that if you don't comply with your mandatory outpatient treatment, instead of just getting put in a hospital for 72 hours, because as she says, no one is restored to sanity in 72 hours. Senator Savino and also Governor Hoko have talked about lengthening the time that someone with Kendra's Law order would have to stay in a hospital if they did not comply. Those are some things that could be helpful.

Brian Lehrer: We thank Dr. Anthony Carino from the Center for Urban Community Services and New York Times Poverty and Social Services correspondent, Andy Newman, maybe you read his story called Decades Adrift in a Broken System, Then Charged with a Death on the Tracks. Thank you both so much for an important conversation.

Andy Newman: Thank you, Brian.

Dr. Anthony Carino: Thank you, Brian.

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