Why New York's Mental Health System Isn't Working
And what Mayor-elect Zohran Mamdani should consider.
In this week’s episode, we talk with Manhattan Institute senior fellow Stephen Eide, author of Homelessness in America: The History and Tragedy of an Intractable Social Problem. Stephen joined us from Norway, where he’s conducting research on mental-health systems to talk about why New York continues to see so many visibly ill people on the streets and subways despite its right-to-shelter protections.
We go through the history of deinstitutionalization, Medicaid’s restrictions on long-term psychiatric care, and how shelters and supportive housing function today. Stephen also describes what he has observed in Norway and how that differs from the challenges New York faces as Mayor-elect Zohran Mamdani moves to create a Department of Community Safety and alter the city’s crisis-response approach.
Stephen’s advice to the mayor-elect:
Lightly Edited Transcript of The Episode :
Liena Zagare (00:00)
Hello and welcome to the Bigger Apple podcast. I’m Liena Zagare.
Nicole Gelinas (00:06)
And I’m Nicole Gelinas. And today we have with us a guest who is an expert in mental illness and homelessness in America, Steven Eide, like me, a senior fellow at the Manhattan Institute and the author of the 2022 book, Homelessness in America, the history and tragedy of an intractable social problem. So welcome, Steven. Thank you for joining us this morning.
Stephen Eide (00:32)
Thanks for having me, guys.
Liena Zagare (00:35)
Welcome to the show and I’m really glad that you can join us from Norway, where you’re currently researching mental health solutions to community problems. Is that right?
Stephen Eide (00:49)
That is, yes.
Liena Zagare (01:05)
But before we talk about that, I wanted to ask you to tell us a little about yourself and how you got interested in homelessness and mental health and came to research it.
Stephen Eide (01:09)
Well, I think it happened for New York reasons. Before I got onto this beat, I had worked on a few other urban policy problems. In the early 2010s, there was a big interest in cities going bankrupt and fiscal problems, so I spent a lot of time researching stuff like the bankruptcy of the city of Detroit.
But, you know, in New York, I think there’s always been a concern about what kind of system failure explains the fact that we just see so many people around who are not getting the treatment that they need. It’s not good for them. It’s not good for other people. Why do we live like this? And that I think was, as a perennial question, but it really reasserted itself in the middle of the 2010s, under de Blasio. And so that’s when I really started engaging with both the homelessness and serious mental illness. Kind of package of issues and over time it just became more and more exclusively my beat.
Nicole Gelinas (02:18)
Can you tell us a little bit about the history? What’s correct about what people think they know, and what’s not correct? I think most people have a vague idea that American states emptied out the mental hospitals starting in the Kennedy administration, and that continued, and Reagan cut spending on homelessness and mental illness, and that kind of led us to where we were before the pandemic. Is that correct? Is there more to the story? How did all this happen?
Stephen Eide (02:58)
Well, if you’re asking about whether homelessness is a housing problem, I am sympathetic to that idea. However, people tend to misunderstand what it means. It’s not as if a long time ago we had expansive subsidized housing programs that everybody used, and housed everybody, and then Ronald Reagan came along and so much for that. We used to have a lot of really bad housing. The famous SRO hotels [single room occupancy] in New York, heavily concentrated in the Bowery, in the Upper West Side, and, long story short, in New York City and other parts of the country.
We decided that we didn’t want people to live in very bad housing, similar to how in the labor market we didn’t want people to, you know, accept the kind of employment situations that were bad. Okay, so all the bad housing went away, housing quality rose over time. But as a result, the people who relied on that very bad housing sort of lost options. And then it really came to a head in the 1980s, and then the government had to start figuring out how to start building back in a much more expensive way than private housing that was lost.
So when people say that California’s housing crisis was caused because the last 10, 15 years, California didn’t build enough housing, I would say that could be an exacerbating factor in the California homelessness crisis, but I think there are deeper, more structural historical reasons about why California had homelessness even before 2010.
As far as the mental illness dimension goes, when I researched the history of homelessness, what I found was that although substance abuse had always been a big part of the homelessness population, had been a driving factor, I didn’t find that people back in, let’s say, the 1950s were talking a lot about psychotic people winding up homeless or living in the SRO hotels. And that was a heavily researched problem. A lot of people wrote about that, it attracted a lot of attention.
So the kind of qualitative nature of the homeless population in addition to the sheer numbers, if you wanted to get into that, you really have to get into the story of deinstitutionalization and how, you know, we kind of made a promise about community mental health care that we never made good on.
Liena Zagare (05:23)
New York City is obligated by law to provide shelter to anybody who asks for it. You know, given that it’s getting colder, a lot of street homeless are searching for shelter in the subway system. What is it that is making it so difficult to help people who are on the streets, oftentimes with serious mental illness, to get into shelter?
Stephen Eide (05:52)
New York’s right to shelter is unique. There was a lot of focus on this during the migrant crisis. I’m not aware of another American city that makes what is frankly a very generous offer in all seasons to all people, not just families, single adults. Even if you showed up yesterday from another country and you have no other place to stay, the city has to shelter you. And that’s what makes it so vexing why some people decline to exercise that right to shelter in New York.
The people who are not in shelter are the people who almost certainly know that there is this offer available to them. They’re very, very hard cases. You push it down to the absolute minimum, the number of people who are those treatment resistant or service resistant cases, but they also get concentrated in Manhattan and the subways and especially the Manhattan subways.
And so, what’s the rest of the city like? You don’t see a lot of street homeless, unlike California where it’s really distributed everywhere. But it is very noticeable and it contributes so much to these quality of life problems that both New Yorkers and people visiting from elsewhere see and consider so defining as far as, you know, New York’s problems.
Nicole Gelinas (07:20)
Is there any way of knowing, do we have more severely mentally ill people today than we had in the 1960s and 70s? Or is it just that this population would have been in the institutions back then? Or is it just that they wouldn’t have been diagnosed back then? They wouldn’t have even made it that far in some cases? Or is it some combination of the three?
Stephen Eide (07:49)
I’m inclined to believe that the people on the subways or the people in shelters who have serious mental illness probably would have been committed to an institution back in the day. Estimating historic rates of schizophrenia is very, very difficult. It’s even difficult to estimate it between different nations, but most people seem to wind up in the default position that between roughly similar societies and roughly similar times, probably the rates are the same. Probably there wasn’t a big increase. It just happens that people were in a different system then than they are now.
Liena Zagare (08:33)
Can you tell us a little about how Norway’s handling the situation?
Stephen Eide (08:38)
Well, I think that in the case of Norway, you have a situation where they basically think deinstitutionalization worked. There’s not the sense of a betrayed promise like we feel when we talk about, you know, bringing back the asylum or what happened with deinstitutionalization. Their community mental health system seems pretty effective at dealing with serious mental illness.
I think there are a lot of questions about what you do with that from an American perspective, but they’re satisfied with deinstitutionalization in a way that we’re not. I do think that they have a lot of questions right now as far as mild mental disorders and people wanting services with that.
The European health systems have always had these long-standing problems with waiting lists and with more demand than they can service in an appropriate amount of time and mental health that’s really escalating. And it does seem to me that an interesting question as to which system is going to be better positioned to deal with that, which is a separate but related question to which system is better at dealing with serious mental illness.
But I do think that probably this issue of the over-medicalization of life is going to be increasingly a problem that we’re going to have to be asking these systems to do something about for a few reasons, cost not least among them.
Nicole Gelinas (10:10)
So when you say Norway is pretty satisfied with deinstitutionalization, can we assume that they went through the same process we did? They decided somewhere between the 60s and 80s, they didn’t want to keep people in institutions?
Stephen Eide (10:29)
Well, they started later than us. That’s a big part of the story. Every Western country that I’m familiar with did deinstitutionalization and none of them brought back the asylum, which is by the way, an important thing to keep in mind if we’re somehow, I mean, I don’t think we will ever bring back the asylum. And one reason why I think we won’t is because no other country did.
Nicole Gelinas (10:35)
Hmph. Okay.
Stephen Eide (10:53)
You know, it would be like reversing some other just gigantic social change, like feminists or something — nobody’s going to reverse that. So we’re going to have to figure out how to make this community system work. But they started later and they started after their health system was built out, which we didn’t really do when Kennedy passed, signed that act [Community Mental Health Centers Act of 1963] into law in 1963.
That was before Medicaid and Medicare and before we really had figured out how this whole third party system was going to work. And so, trying to braid together the mental health programs with the bigger health system has always been a challenge. And in retrospect, it would have been better to have that health system ready to go before you started asking it to do mental health too.
Nicole Gelinas (11:48)
And before we talk about, is there a better way to do this? Maybe you could tell us how New York approaches both the separate problems of mental illness and homelessness. What’s the state’s role? What’s the city’s role? What’s working? What’s not working?
Stephen Eide (12:09)
Well, traditionally mental health was an exclusively state responsibility. All there was in terms of public mental health care were these big asylum programs. The biggest one in world history was Pilgrim State on Long Island, which had something like 12,000-13,000 patients total.
A big change comes when the federal government gets involved in that, and, similar to what it was doing with education, all these previously state and local responsibilities, in the sixties with the passage of Medicaid, for example. And then over time, the city government enlarges its share of responsibilities. And also just because people look at the mayor as this really important person who just needs to fix whatever problem they have in their life. That’s a kind of natural New York thing. The city gets more involved. And at times, you know, the mayors, they welcomed that. They can’t say no. And de Blasio was especially unwise about this. There wasn’t really a distinctive Bloomberg mental health policy. It remained pretty much a state responsibility at that time.
But de Blasio, for various reasons, decided he wanted to make mental health a priority. And so he welcomed that responsibility without really knowing what he was getting into, I think. So as a result, it’s kind of muddled right now who is in charge. Ultimately, the state and federal government are the most important players. But as we saw with the Mamdani campaign, and just in the way that ordinary New Yorkers think about this, there is an expectation that the city government needs to be doing something about mental health, that it kind of owns by this point. But it is quite an awkward fit, I would say.
Liena Zagare (14:02)
What can the city do?
Stephen Eide (14:05)
Well, the city is going to be involved in anything that has a public safety dimension. So police are going to be involved, although as we might talk about it later, Mamdani would like this police to be less involved than they are now. There is a Department of Mental Health and Hygiene. It hands out contracts that provide some services. There is the city hospital system, the Health+Hospital system, and that provides all kinds of healthcare. That’s a very important role.
And in fact, that’s arguably the most important role of the city, particularly in responding to serious mental illness. Because when we think of stabilizing people in crisis — people with schizophrenia are gonna need various things, but we’ve got to first of all stabilize them. And that’s gonna happen in a hospital, Health+Hospitals uniquely in New York City has a big role to play with that. And so any kind of city response to serious mental illness will very, very heavily involve that system.
Nicole Gelinas (15:14)
And you talked about de Blasio taking on more responsibility in a superficial way. Did that coincide with the state cutting back on mental health beds? And now that we don’t have asylums, what does a mental health bed mean?
Stephen Eide (15:35)
Yeah, the old what was left of the old asylum system or what is left of it is called psychiatric centers state psychiatric centers that are run by the OMH, the Office of Mental Health, state psychiatric hospital beds are set up for long-term commitment of people who need to be held for a while as opposed to kind of a short term like basically triage at Health+Hospitals.
Andrew Cuomo really did not like state psychiatric centers. Cuomo started working on homelessness and related issues very, very early on in his career So, he did know something about these problems But he also had very fixed views and he’s pretty consistently in his career felt that he doesn’t like state psychiatric hospitals even in terms of his recent campaign. He was still criticizing them.
One reason why you don’t like that type of model is it locks up these resources in a very expensive program that not as many people are going to benefit from. If you want to spread resources around, you take resources out of state psychiatric hospital beds and put them into various community mental health programs. And that’s what Cuomo did in the 2010s.
While de Blasio was sort of doing what he was doing, trying to do something about mental health with Thrive NYC, Cuomo’s cutting beds. And those cuts coincided with increased mental health related pressures on other systems, notably city systems. So the city-run homeless shelter system will experience more pressures if the state-run, mostly state-run mental health system is not doing its job. And so it became kind of a Cuomo versus de Blasio thing, although people didn’t really pay as much attention to that. This aspect of it is another part of that squabble. That in city pressures, pressures on city systems related to untreated serious mental illness increased. The jails, the homeless shelters, more cops getting calls and stuff like that.
And that was a really important legacy of the Cuomo administration. But finally, under [Governor] Hochul, for various reasons, the bed supply has stabilized and in a modest way, we’re finally adding more beds, which is to say, deinstitutionalization at long last is finally overwritten, at least in New York state.
Liena Zagare (18:15)
Do you think there are enough beds at this time?
Stephen Eide (18:18)
No, I think we need to add more beds. I think that you have a lot of seriously mentally ill people in the wrong system. They’re in the jails, they’re in housing programs that are not capable of handling them. And if we invested more in beds, that would relieve pressure on those other systems and it would relieve pressure on the transit system too.
Nicole Gelinas (18:41)
And on Liena’s question, how many beds are we talking about here, both statewide and that the state runs in the city?
Stephen Eide (18:51)
I’d have to look at it. I don’t know it offhand.
Nicole Gelinas (18:55)
Well, how many do we have? What’s the population that we’re talking about here? And I guess how many do we need?
Stephen Eide (19:02)
I just wrote a report on that a couple months ago, so I should have that at my fingertips, but I don’t. I would refer you to my deinstitutionalization in New York report How many beds we need is – it’s hard to know, honestly. People have put out various estimates. It’s hard to benchmark against other systems.
A bed in a state psychiatric hospital is a different kind of thing than a bed in Health+Hospitals. It’s a different bed run by the New York Presbyterian Health System. They kind of have different purposes. Figuring out what the right mix of those is and ultimately how many we would need. I’ve never been sure that I would ever get a perfectly clear answer to that if I set myself to it. And also I just felt like it’s, you know, it’s such a crisis and it just seems like such a great need. And I’m not the only one who feels like this, that just saying more is persuasive, no less people.
Liena Zagare (20:10)
And when you talk about beds, it’s not just a physical bed. It also involves a lot of support personnel, right?
Stephen Eide (20:19)
Right, the staffing, yeah. And that’s why, you know, this is nothing like bringing back the old snake pits, you know, the back when you had Pilgrim State with 12,000 or whatever it was patients. The staffing was really hard there. And so that’s related to why the conditions were so poor in many state hospitals. Especially in other parts of the country, which didn’t invest as much as New York did.
New York has always invested more than states in the South. So the staffing, yeah, which is downstream of the kind of quality concerns that we have. And we have quality regulations on state hospitalization that we didn’t have back in the old snake pit days. So it costs a lot of money and that’s why the federal government ultimately would have to be involved. But in my view, we should just kind of own that.
Liena Zagare (21:10)
Are there enough people willing to work in psychiatric wards?
Stephen Eide (21:15)
Well, the mental health field does talk a lot about its workforce shortage. It’s not the only field that talks about that, but they say that they don’t have enough workers. And there are lots of people who work in mental health somehow, you know, therapists in private practice, people who work in schools.
It is a challenge though, getting people to work with the seriously mentally ill, especially if you’re talking about psych hospitals, there is the risk of violence. If that person is in a family with a spouse, maybe that spouse doesn’t like the idea that that’s where they would prefer to work. And if something bad happens. You think maybe, if you’re young and idealistic, that’s where the need is and you really want to devote yourself to it, you throw yourself into it, but then something really bad happens to you and so much for that.
You have to work with people who, in some cases, have done really terrible things in terms of the crimes they have committed, the things that are in their past, and you have to be providing a kind of therapeutic service to them.
So that can be difficult to overcome. We have a demographic decline generally, as I said, lots of other places experience shortages, mental health is not unique, but we do have to make sure that we have enough people who want to work with this seriously mentally ill.
One last factor is – sometimes seriously mentally ill people don’t get better. It’s often referred to as a chronic condition. And if your idea of practicing medicine is seeing the results of your interventions and seeing people happily walk away like after you gave them a hip replacement or something like that, providing services to the seriously mentally ill is not always like that. So that’s another reason why some people who could do something else sometimes do do something else.
Nicole Gelinas (23:16)
And on that topic of the risk that people don’t get better, who is a candidate for long-term hospitalization? I mean, if I’m just walking along into the subway and I see someone screaming and ranting and raving and obviously in a case of bad hygiene and, you know, obviously not in their right mind, is that a person who should be in the long-term hospital or is that a person where if he were sent and stabilized for 72 hours as you said the state and city should take a different approach and how would you know before we start to get into what that approach would be?
Stephen Eide (24:05)
Clinicians, if you talk with them, they would be able to cite examples of just miracles, people who were a complete mess and yet somehow stabilized and were able to live something resembling a normal life with lots and lots of support. Addiction services are like this too. But they would also say that they just don’t know. And certainly there were people who they thought were promising cases and they let them down.
Yeah, from the start, it’s hard just coming on to somebody who you know very little about. It would be probably impossible to make that call if there’s someone who needs to be committed for quite a long time. Knowing something about their history would probably tell you if they’ve just been unresponsive to treatment forever, basically. Maybe if the medication just actually doesn’t work with their symptoms, that would be useful information to know.
But, again, getting back to how I think about this from a crisis standpoint, I think that you would want a continuum of options to put people in, and you would want people to be sure that they are making that decision about how long they stay based upon clinical reason, not financial pressures stemming from shortage.
Nicole Gelinas (25:29)
We hear about this so often and during the case of the trial of Daniel Penny, who was accused and acquitted of killing somebody on the subway and that somebody, Jordan Nealey, was in the middle of psychosis and had a long history of being hospitalized by both the city’s public hospitals and private hospitals for psychosis.
But he was constantly released. I mean, we could read his medical notes in the courtroom, which normally you can’t do because of privacy laws, which I guess is good, but in this case, we could get some insight into this. Even in the public hospital, his doctors were saying they had to write down the justification for keeping him in physical restraints. And they basically said what you just said, that he was dangerous and they were afraid that he was going to attack them. So that’s why they had him in restraints.
But yet, even though they were afraid of him in a controlled setting, they kept releasing him over and over. So is it because of financial constraints that the hospital has to let him go in 72 hours because they don’t have insurance money? Because they need the bed for somebody else? Or is something else going on there that’s forcing this release over and over? And we hear this all the time when somebody commits a terrible crime, the papers will go to their family members and the family members will say, we tried to get them hospitalized and they kept letting them go. So why does that happen?
Stephen Eide (27:07)
Yeah, the family perspective, which I think a lot about, is usually a perspective that points to the need for more beds. Also the people on the inside of the systems like psychiatrists would normally say, yeah, we need more beds. Why it happens? Well, you have to think about the kind of nexus of legal and financial considerations.
The first thing that people say is that, well, there are legal criteria that determine, you know, whether or not you can commit someone, does he have an underlying psychiatric disorder? Is he dangerous? And can he not be treated in a less restrictive environment? So you go through these criteria and dangerousness. There’s also this related criteria in New York of not meeting his basic living. So he’s deteriorating, like his health is awful. And because he’s not taking care of himself because of the psychiatric condition, then you can commit them.
When they are treated the symptoms go down they no longer meet the legal criteria and so they have to be out. But when people have talked about the history, why the system works like it does, the cyclical nature of cases like Jordan Neely, people riding the institutional circuit, some people have argued that fixation on legal standards and trying to make it easier to commit people on a legal basis is just less important than the financial considerations.
And within these systems there are these pressures that are applied one way or the other to, like, if someone’s staying for a long time, the doctor who has to make the decision about whether or not they can stay committed will start getting more and more scrutiny. Someone is going to be in their ears saying, like, is it really the case that we can’t keep them because it’s so expensive and other people are trying to make their way into these beds. And so it’s a subtle thing. And the official reason will usually be the legal explanation. But you have to think about the financial engineering behind these systems to really understand why people are constantly on the circuit.
Nicole Gelinas (29:16)
And that’s fixed with more money. Are the people who say we don’t spend enough money on this, are they right?
Stephen Eide (29:24)
I think that more money would help. That’s why, you know, Medicaid currently can’t pay for it. If Medicaid, meaning the federal government and New York has a great reputation for figuring out how to bill federal government for things it wants to pay for, that would kind of just relieve some pressure in the system. And they would, there would just be slightly less scrutiny on keeping people.
Nicole Gelinas (30:01)
And why can’t Medicaid pay for it?
Stephen Eide (30:04)
Well, Medicaid has this provision in it called the IMD [Institution for Mental Diseases] exclusion, which was put in place in the program in the 1960s when Medicaid was created because the federal government didn’t want to pay for long-term institutional care. And that prohibits a specialized psychiatric hospital, the type of hospital that’s set up for long-term or intermediate term care from billing Medicaid for that cost. So a general hospital, a short-term hospital like Bellevue could bill Medicaid, but the state psychiatric center system can’t. And so that creates these kinds of pressures.
Liena Zagare (30:39)
So let’s talk a little bit about the Community Safety Department that Mamdani is proposing and the approach in general in how best to intervene when somebody calls 911 that someone is in crisis. I believe he wants a different number to be called when someone is experiencing a mental health episode. What is your take on the proposal?
Stephen Eide (31:08)
You know, it’s not that new of an idea. It’s been kind of in the mix of this conversation for a while. If you want less police involvement in emotionally disturbed person calls, EDP calls, there are things you can do about it. If you don’t like how that’s going, you could retrain police. So under de Blasio, they started up this deescalation training problem called TRACE, crisis intervention training. So, you know, doing that.
Okay. Then you can do these co-response teams, which I know Nicole has written about, where either you’re doing it in a kind of proactive way, but you’re pairing police with clinicians, social workers to get out and reach people, or you just get rid of the cops completely, and getting rid of the cops completely – a non-police crisis response – is what the Mamdani people really find attractive.
As with so many of these Mamdani proposals, there’s a lot to talk about in terms of the practical difficulties with this. But I have a couple difficulties with the premise of this.
First of all, all the energy behind this kind of non-cop response proposal has always been motivated by this idea that cops just don’t know what they’re doing as far as mental health and mental health professionals do. And I’ve always had difficulty with that premise. A cop who works on patrol in Penn Station and Grand Central will actually know a surprising amount about serious mental illness. A mental health professional who works at a school or as a therapist or something may actually know less about untreated serious mental illness than a cop does.
The number of really, really terrible things that happen, meaning cops shooting somebody who is completely unarmed, not a threat, and completely mistaken overreaction is very small. It’s a very rare thing. Yes, it happens sometimes. America is a big country, but that you need to do this revolutionary change in crisis response to deal with that problem in particular seems like just a lot. So I think that energy has a lot to do with ideology, that it would be good to reduce the role of police in American society.
I mean, these arguments that you’re actually helping, doing the police a favor, it’s going to create a more efficient police department, I think can mostly be put aside. I don’t think people really care about this. Just like, can you claim victory by reducing the role of police? That’s really what this is about. And I think that that’s not a goal that I share in a basic way.
Liena Zagare (33:59)
Are police involved in such calls in Europe?
Stephen Eide (34:03)
I don’t know, I didn’t have as many conversations about that as I should have, but the presence of guns affects all of this. The risk that there might be some weapon and especially a gun influences our whole crisis response system and why we do this in such a more sensitive way than they do.
Nicole Gelinas (34:31)
And when Mayor-elect Mamdani talks about taking police off of these co-response teams, this is not something where we’ve been doing it like this for 30 years and he wants a different approach. These are new programs.
The MTA started its SCOUT program about a year and a half ago where they have a clinical nurse go out, and that person is backed by a team of three MTA police in the subways, and go and approach people who appear to be in distress. And the nurse does all the interaction with that person. The police are only there in case that person becomes agitated or dangerous, or if the nurse decides that person needs to be involuntarily transported to the hospital, then the person can’t just walk away if the police are there.
And the city has rolled out a similar program called PATH. Same idea, civilians backed up by a team of police. This is something that the Adams administration is very proud of, roughly over the same year and a half time frame. Do you think those programs are working? Have they made a big difference in the past year and a half in both the actual people getting better, more thoughtful help? And people walking around seeing there’s less disorder on the streets and subways?
Stephen Eide (36:05)
Well, I’m not sure, as you say, it’s new and we’re talking about a very big mental health system that would require a lot of things to fix. And by the way, that’s one of the biggest flaws in the Mamdani thing. You’re gonna have to spend a lot on this stuff and it’s just a diversionary program. People are not getting diverted into the criminal justice system, they’re getting diverted out of it, to where? Where are they going? You’re spending all this money not on treatment capacity, not on the actual system, just on this kind of front end.
But anyway, the co-response stuff… Well, one of the big selling points of why getting non-police response is such a great idea is there are these little programs out in these other Western cities that seem to be doing something like it. And someone you talked to somewhere, or some article you read somewhere, said it was great. So New York should do exactly what Eugene Oregon does or did before it ended that program.
Well, I read in an article that other cities have been coming to New York or inquiring about New York to learn more about its co-response coverage. Maybe thanks to your glowing profile of the work it’s doing. So if one standard of success is do other people or other people interested in your model, New York seems to be doing okay. It’s just as good with co-response as other, as Eugene Oregon was doing with CAHOOTS.
I think it’s a sensible model. If you think about what does a clinician need to do their work, to feel free to do their clinical stuff, not having to worry about safety because that box is checked seems attractive to me.
We were talking earlier about how you possibly find people who want to do this work. I would think you’re gonna have to pay people quite a lot. That is a decline in working conditions, if you have to work with people who are unpredictable and have untreated serious mental illness with none of that kind of safety net that you’re normally used to working with, it’s going to be a workforce recruitment challenge for sure.
In California they do all this work with encampment resolutions, breaking down encampments. The sanitation workers have been pretty consistent in saying, I’m not interested in going into an encampment and putting my hands all over people’s stuff without the police backing me up doing that work. So I don’t know what’s so wrong with co-response.
I think you definitely want medical professionals involved, particularly if you’re interested in evaluating people for involuntary commitment. That’s another qualitative difference between co-responses, the city in particular has set it up and the Mamdani plan.
You’re really focused on hard cases people who might possibly fulfill commitment criteria getting them into treatment That is something that it is actually a good idea that you want medical professionals involved with as opposed to just cops because cops are going to take a little bit more of a kind of harm reduction approach with those cases. So based upon everything I know about how to manage untreated, serious mentally ill in public places, co-response seems sensible enough to me, but I don’t understand why this other, much more difficult program would be so necessary to go through with, amidst all the other things that they’re hoping to go through with, other than just basically ideology.
Liena Zagare (39:57)
Do you think there are negatives to this proposed program? Like, what could go wrong that isn’t going wrong right now?
Stephen Eide (40:07)
You mentioned earlier how they want to have this other line that you can call you. So you call 988 because it comes down to when do you have a call that is just mental health and violence has nothing to do with it. In terms of the implementation, everything comes down to that. The dispatcher has to be able to figure out when it’s that kind of call.
If you want to do this at scale ,and at times they’ve talked in that’s apparently what they want to do, a big program at scale system-wide, you are definitely going to raise the risk that you will code a call wrong. There is a risk of violence there.
Or, and this I know for a fact has happened in other cities, somebody will call the 988 number and say, this is an incident that’s just a mental health incident. And someone else will call about the same incident and say, this is a 911 call, this is a violent call, you need police response. If you’re calling for emergency assistance, something is going wrong and you want to make sure you have, you know, police just there if for no other reason than backup. That is the public demand just from a consumer perspective.
So if you wind up in the situation where dispatchers are re-educating people or you’re really just pushing hard to send more of these mental health teams out and something goes terribly wrong with one of the mental health workers, or with someone on the scene, you know, you’re going to have to own that. And maybe they will say, well, it’s rare or it’s, you know, we handle so many other calls without incident, you know, but guess what? That’s what happens now. We handle all these calls without incident.
Nicole Gelinas (42:07)
Yeah. It’s going to take more time to dispatch because the dispatcher is going to have to ask more questions and time is of the essence. No matter who shows up, I think, as you said, you know, something is going wrong. So the seconds matter. Taking another 30 seconds to ask these questions is adding to the response time. And plus, the difficulty when so many of these calls are behind closed doors.
If somebody hears a woman screaming, you know, bloody murder in the apartment next door, she could be having a mental health episode or she could be being attacked or it could be both. And that someone is trying to stop her physically from harming herself. And it’s going to be confusing and the confusion might not be sorted out until after, which is why some of these reports of ‘retroactively, this could have been coded as a mental health call.’ Well, it doesn’t help you after, you didn’t know it before.
And, I’ll just give you a number. The city puts up a monthly dashboard on involuntary transports for psychiatric evaluation. So the monthly average since January, 2025 is 414 a month initiated by police and 78 a month initiated by clinicians. Some of this is, of course, that we only have so many of these PATH teams. I think there’s five; and police are out there all the time. But the level of clinicians scale up you would have to do, nevermind, you know, should they have police behind them or not, it’s an enormous increase in the size of the sort of street and subway mental health field, which as you said, creates a big workforce recruitment issue for difficult working conditions as well.
Stephen Eide (44:08)
And there’s already a shortage. There’s already a shortage of mental health professionals and we are in a demographic decline and we’re going to basically invent a new mental health profession in the middle of all that.
Nicole Gelinas (44:18)
Now one area where we’ve, the city has used and almost everybody always says this is a good idea, is supportive housing. When people say, okay, there’s mentally ill people on the subway, we need to do something about it, almost every progressive politician, liberal politician, even moderate and conservative politicians, (except, of course, more moderate and conservative people don’t want them in their neighborhoods), is, we need to build more supportive housing. These people would not be on the subway or street if they were in supportive housing units. So what is supportive housing? Where did this come from and does it work and do we need more of it?
Stephen Eide (45:05)
Supportive housing is part of the homeless services system. It handles people with serious mental illness, but it’s considered a homelessness program. It was invented in New York, and New York has an enormous amount of supportive housing units. I wanna say something like 35,000- 40,000, or something like that.
And so New York has been building these units for a long time. It’s affordable housing just like any other, but paired with some sort of social services there to help stabilize people in that unit, to make sure the housing works out and basically to keep track of people.
Traditionally supportive housing in New York City was delivered either in the form of a voucher. It’s called a scatter site where you would just find a landlord who was willing to take this voucher and you would put this formerly homeless person in an apartment and they could stay there for the rest of their life. It’s a permanently subsidized unit. Permanent supportive housing, PSH, is what it’s called in most of the rest of the country.
Or, there was project-based PSH, or supportive housing where you would build a new building. And New York City has some very famous project-based supportive housing buildings. But as is the case elsewhere, you’re just never able to keep up with the demand. You’re never able to build enough to keep up with the flow of people falling into homelessness or just staying in homelessness, waiting for their unit.
Recently, New York had to basically stop scatter site housing because providers said they just couldn’t find people to take the vouchers. They were unusable. So now your only option is to build buildings of supportive housing. In theory, using the voucher should be more efficient. It should be quicker. If you’re gonna have to go the project-based route that looks kind of glacial, but that’s a situation that the city is in.
As you say, there’s no problem with the political will, at least in part of the city, politicians and state politicians, and the money’s been there as well, but still bringing the units online in a way that can make a meaningful difference. New York’s street population, you’ve participated in the HOPE count, when we go out and do the HOPE count, it’s been pretty flat for a while.
And New York City has been adding all these supportive housing units. So you would have thought that the street population should go down because that’s really the type of population that everyone said is ideal for supportive housing. And it’s worth doing. We’re going to keep doing it. But as much effort has been put into it, it just hasn’t registered as much in terms of net reductions in the homeless population.
Nicole Gelinas (48:12)
And why won’t people take the vouchers for scatter sites?
Stephen Eide (48:18)
Well, it’s a hard program. I mean, you’re talking about somebody who’s been homeless for a long time, who has no family. They certainly don’t work. They’re on SSI probably. Long, serious behavioral health problems. And they’re gonna be put in some building, a normal apartment building. And the nonprofit who’s participating in this program has to manage any friction that results with this landlord who’s for whatever reason wanted to participate in this.
If there’s difficulty with the neighbors or if there’s difficulty with the landlord, you’ve got to find another unit pretty quickly. The building is sold. There’s just a lot of instability associated with PSH that’s voucher based as opposed to when you just control the building. More of a risk.
Liena Zagare (49:22)
So where do people end up? Where do people end up out of these situations? Do they go back to shelters?
Stephen Eide (49:28)
Permanent supportive housing. I mean, so it’s, you still deal with the same housing court in New York City when you’re dealing with permanent supportive housing. You may very well have evictable cases, people who, in another community, because they decided they don’t feel like paying rent anymore or they’re trashing their apartment, that’s another thing that causes friction with landlords, hoarding. That would be an evictable case in other jurisdictions because it’s so hard to evict anybody in New York, including a permanent supportive housing tenant.
The rate of retention in permanent supportive housing in New York City is high and also just because providers are not gonna go out of their way to evict people because they don’t like that idea. So they stay in these programs for a long time at pretty high rates. But yeah, that’s what happens.
Nicole Gelinas (50:22)
And there is violence. Just last week, we had a supportive housing person stabbed to death by another tenant, and we had a shelter murder. So here’s one really basic question: how do we make the shelters safer? You mentioned that Curtis Sliwa, the mayor candidate said in the debate, one of the moderators asked about homeless policy and Curtis Sliwa said, just make the shelters safer. Is that a good goal and how do you do that?
Stephen Eide (50:58)
I think that’s a very sensible policy idea. To reduce street homeless, make the shelters safer. I think it’s going to be hard, but that’s as good as an idea as I’ve heard about how to improve, you know, conditions.
The shelter system in New York has its own unionized police force, basically. It’s the shelter security guards. They use some private security staff, but they also have these safety agents. It’s similar to the situation with the schools. So they’re unionized and it’s expensive, you know. And the idea is that you just need to ramp up that. Well, spending more money on the shelter system, which is already a unique multi-billion dollar enterprise, is something that progressives don’t necessarily love the idea of, because that’s all this money that’s not going to permanent housing.
So if you believe that the only thing that fixes homelessness is permanent housing, homelessness is a housing problem, period, you want to maximize the resources going to permanent housing. That means you are going to be a little reluctant to pouring more money into the shelter system, and the shelter system has a bad reputation. Always has had a bad reputation. No one is defending it.
They’ll defend the right to shelter in the abstract. So I actually think it’s a very honorable thing to try to defend that idea, the shelter system. You’re doing that by trying to connect, trying to persuade people to go into shelter, ‘it’s not everything you want, you you’ve had a bad experience, please give shelter a try.’ I think if more city politicians got behind that, that would be better. But getting back to the shelter safety idea. In addition to the spending dilemma, you also have the problem that people just want completely different things.
Some shelter clients say the reason why they don’t come into shelters: ‘there are too many rules. I want more freedom.’ And some people say: ‘there aren’t enough rules. I feel unsafe.’ Obviously, giving more freedom is going to lead to more safety issues. So it’s an issue of behavioral regulation and not just money, as is the case with so many social problems.
Liena Zagare (53:27)
I was wondering how long do mentally ill people stay in shelters and whether they are not de facto affordable housing in this situation.
Stephen Eide (53:37)
Yeah, they can stay a long time. The they’re waiting. You apply for supportive housing, you get in the queue, and hopefully someday your supportive housing number comes, up and you agree to accept the unit that’s made available to you. Sometimes they decide they don’t want that particular unit. They want to keep waiting. So it can be a long time.
There are specialized mental health shelters in New York, so it’s not like you’re just living in a big room and no one’s doing anything for you. There’s some sort of clinical resources that are made available to you while you’re in shelter, but it’s set up to be a temporary accommodation. That’s the idea, just like it is in any other city shelter.
Liena Zagare (54:23)
Oftentimes you see people who are homeless with animals and as far as I can tell most shelters do not allow animals. So are there shelters that allow animals? How does that work?
Stephen Eide (54:40)
I can’t remember what the current protocol is in New York City, but that comes up all the time. I think this is a California thing. If you go back to homelessness in 1980s, animal management questions, the allowing pets question, you just didn’t see as many homeless people with pets back in the 1980s. I think California exported this to the rest of the country. That’s my hypothesis because people on the street in California, just so many of them have pets and so it becomes this low barrier issue.
It’s similar to the substance abuse. Say, if you require sobriety to enter into a shelter, you’ll have a better shelter. It’ll be a more orderly shelter that some people would say that’s exactly what it would want. But then you deter the people who say they’re not ready for sobriety.
Animals, even non-homeless people can get into fights with each other over animal management. Someone’s not keeping track of their dog, your dog lunged at me. No, it didn’t. The two dogs are not getting along. I also think it restricts you. I think it would be great if we discouraged pet ownership amongst homeless people.
I think it would fix a lot of problems, not just in terms of the shelter, but what comes after shelter? Are you going to be able to get a job? What’s gonna happen when you have to look around for jobs? You take your dog with you around all that? Are you gonna be able to find a roommate or a landlord?
Finding a landlord and roommate is just gonna be a little bit harder when you have, when you insist on having a dog. So our normalization of dog ownership amongst the homeless was a really bad issue and accommodating pet ownership in shelters, although it follows this kind of low barrier logic would end up encouraging more pet ownership amongst the homeless.
Nicole Gelinas (56:26)
I have a two-part question. Should supportive housing and other types of longer-term housing for the homeless and mentally ill require work? Right now, permanent housing doesn’t require people to work, even if they’re of working age and seem like they would be able to work. Would that actually be good for them to have to stick to a schedule and be someplace every day, get dressed every day, and also reduce some of the incidences of street begging because some of the street and subway beggars are not homeless. They’re actually in permanent housing, as we saw in that New Yorker article a couple of years ago. And also some of the petty theft. I mean, the same article showed how to get extra cash other than what they were getting from benefits.
A good number of these people were engaging in petty theft and then fencing the goods on Amazon and Facebook Marketplace. So would it be better to have a work requirement or is this like having a dog where the people wouldn’t do it so they would just be out on the street?
Stephen Eide (57:42)
This question that you just asked is about to be thrust into the spotlight within a matter of days, most likely, because the Trump administration is about to make changes to the federal homelessness grant program, which will have implications in New York and elsewhere.
It has a lot to do with this housing first low barrier question of, can you ask anything of people who you’re giving housing benefits to? Is it the case that you shouldn’t ask people anything because it will deter them or everyone has to make their own process of recovery at their own rate?
Under current protocol, you can’t ask people anything. You give them housing. You make services available. If they use the services great, but if they don’t, they still get the housing. And I think you would get better housing programs if providers had the ability to require people. Before you bring someone into your program, you make clear to them, okay, we want to house you. You’re going to be able to stay here, but we do things in a certain way. The people who live here, they’re active, they participate in services. So, if that’s something you want, that’s great, but you really need to work with us here because if you’re using drugs or not participating in services, that’s gonna be bad for the other people who are trying to build a slightly better life for themselves.
I definitely think the pendulum under the Housing First homeless services, the way these programs are run is under a very, very progressive ideology influence. And so they’re going to be pushing back in the opposite direction. Where we wind up, I’m not sure, but I think if we were able to ask people something, you would have better programs.
Nicole Gelinas (59:25)
And the second part of my question was, you said we have 30, 40,000 supportive housing units. That’s a lot. It would be either more than 1 % or close to 1 % of the city’s total housing stock. Should people expect that if you live near one of these sites, which the numbers mean a lot of people do, that laws against petty crime and disorder outside of them should be even more strictly enforced?
In other words, if you’ve got a hundred people living in supportive housing and some of them are going outside and openly using drugs or using their nearby subway to beg for money so that they can feed their drug habit or just so they have some petty cash or they’re just engaging in disorderly behavior outside. Should it be expected that that won’t happen?
Stephen Eide (1:00:37)
Well, I think so. I understand the argument that some neighborhoods will just never accept anything. That’s what some people on the inside of these systems of progressive homeless services administrators, they argue in bad faith. There’s like, you can’t argue with neighborhood groups. Neighborhood groups are just cruel and racist or something. And so they’re all the same, but I think that it would go better if you made a credible promise that actually conditions will be very, very orderly around this building.
Oftentimes when people make the argument for permanent supportive housing as a solution to street homelessness, they’re essentially saying to you: when people go into housing you will see street conditions get more orderly. You hear it a little bit more often in California, but New York is part of the promise as well. You want better subway conditions? So do I. That means we need more PSH. But neighborhoods who have been involved in those conversations, there’s so many broken promises, so many promises that were made that were never even serious.
So if you were able to have some sort of specific protocol, or just were in the habit of making a specific, you know, promise and making good on that promise that the conditions would be safe and orderly, I think it would help with the siting issue.
Nicole Gelinas (1:01:58)
Right. So you’ve spent time in Norway, twice now, and you’ve been to both inpatient psychiatric settings and community settings. What can we learn from Europe or is it just its own world and we can’t learn anything?
Stephen Eide (1:02:20)
Well, it’s not going to be simple, you know, translating the lessons of Europe to America about any of these questions. I wrote an article for City Journal in the last issue about how New York is a little bit more European than most of America just because of the expansiveness of its local welfare state on top of the federal welfare state. And so it’s a little bit underwhelming that the conditions in New York are not better than other American communities who do so much less. I think that if we had a more centralized community mental health system, somehow that would be better.
That is, with the old asylum system, that was very, very centralized. Then we moved to a more decentralized system where people, instead of going off to some asylum somewhere, could get services somewhere in their community. Okay, that’s more decentralized. What we wound up in America is very, very fragmented. And so, if we had a more centralized system such that if someone said: I have a son who’s living with me. That is, he has housing, but he’s really beginning to deteriorate. And I need to figure out what’s available to me in my particular community. They have a clearer answer to that than we do. So if we could somehow figure out a way to centralize our community system, that would be better.
And there are just these, you know, these other questions about a path dependence and history that we can’t change and social conditions. If you don’t have to worry about clouds of marijuana smoke everywhere, it’s probably, you know, you don’t have your mental health, you’re making your mental health systems job easier than is the case here.
Nicole Gelinas (1:04:21)
Are drugs making mental illness worse? We didn’t talk about drugs and the one issue with the PATH and SCOUT oo-response teams is if a person is just high on drugs, once they stop being high on drugs because they’re in the hospital, the hospital just lets them go, even though they’re probably just going to do the same thing. I mean, how much is drug-induced psychosis contributing to this?
Stephen Eide (1:04:50)
Mentally ill people use drugs, all drugs, all substances, including alcohol, at a much higher rate than people without mental illness. And there is this old debate about why.
The most common explanation you hear is self-medication, but that’s a little strange because they’re using different types of drugs, like they’re using stimulants and they’re also using opioids sometimes. So what symptoms are they trying to control? Because these drugs have completely opposite effects. And sometimes they seem to be using just because they like using drugs, or because they’re in social circumstances where that’s the normal thing to do. That is, they’re using drugs for normal reasons. But controlling it always winds up to be a difficult thing for people who don’t have a lot of other stuff in their lives.
I was never enamored of the involuntary treatment for addiction, idea that the Adams administration tried to promote, because we still have a lot of trouble with involuntary treatment for serious mental illness. I would prefer that we’d fix that first before moving into addiction. But I don’t know what to say because it’s a very similar issue with crime. If you just had less normalization of crime in some of these neighborhoods, then people who are in unstable circumstances wouldn’t be tempted to participate and be less likely to deteriorate.
But if we do policy work, you know, you’re not supposed to say, in order to fix, you know, the particular problem here, we’ve got to fix everything else first. You’ve got to figure out how we might be able to make the mental health system a little bit better while we don’t do anything about all the guns in circulation.
Liena Zagare (1:06:45)
Right. When you mentioned self-medication, I’m wondering about how difficult it is to procure psychiatric medication, which these people would need on a regular basis and how complicated it is to ensure compliance with them taking it. How expensive is this medication and how difficult is it to, you know, actually take care of people who are out on the streets?
Stephen Eide (1:07:12)
Well, in New York, Europeans have this idea that no one in America has health insurance. In New York especially, you would qualify for Medicaid. You may not be on it. You may not be able to use it at every provider around there, but you’ll be able to access health care. You certainly be able to access in the hospital regardless of whether you’re on Medicaid at that time or not.
So paying for it, I’m not saying it’s not an issue at all, but probably bigger issues are just relating to what we call the treatment resistant. First of all, some people just don’t accept their diagnosis. They don’t think they’re seriously mentally ill. Why would I take psychiatric medication if I don’t have a psychiatric problem?
The side effects of the medication, the strange things that happen with your kind of muscles and stuff and your weight gain, that’s very undesirable so there’s is this calculation, a rational decision for some people, that they would prefer to take the symptoms as opposed to the the side effects. So there are a number of reasons why people resist medication treatment for serious mental illness other than just the cost.
Nicole Gelinas (1:08:39)
Are drugs making people more mentally ill? Is there truth to the idea that, you know, smoking marijuana all day in your bedroom is going to make you schizophrenic?
Stephen Eide (1:08:53)
I think there’s two sides to that question. There’s the question of whether or not heavy marijuana use gives someone serious mental illness. Gives someone schizophrenia. They don’t have it in their family background or something. And there’s nothing else explaining other than there’s this compulsive use of this really potent cannabis product. So there’s that question.
And then there’s the question of the people who are already psychotic, how they get it we’re not sure, but they are not living their best life. They are not committed to this treatment program. They’re not showing up to their appointments. They’re not taking their medications. They’re engaging in street drugs or legal drugs in the case of marijuana. I think that’s another, I think that’s a big reason why. It’s basically a barrier to treatment.
We’re talking about what are the barriers that exist why someone is not engaging in treatment. And treating schizophrenia, you know, it’ll never be a perfect science, but we have to commit ourselves to this argument that your life is going to be better. Your life will be better, even if there are side effects, if you commit to treatment than if you just sort of take things in hand without the the assistance of mental health professionals. For most people, that’s the argument that we as general policy researchers need to be committing to. And drug use is just a barrier to treatment like so many other things.
Liena Zagare (1:10:21)
Should we be focusing on people earlier in their lives? I’m thinking, you know, 20s, late teens, when a lot of psychiatric problems seem to appear, as opposed to trying to intervene? Well, not maybe as opposed to, but isn’t it harder to intervene when somebody is in their 40s and has been suffering from illness for a lot longer?
Stephen Eide (1:10:43)
Yeah. It develops around that time. College age is a typical time for when it develops. And, and a lot of people believe strongly in these interventions called first episode psychosis, where you intervene just in very targeted, professional way with somebody who’s having that first break. And they really believe that if you do that, a lot of people will not wind up down this bad path.
How you would kind of scale that up I think is an interesting question because you don’t want to, there’s no blood tests for these types of things. You can’t know for sure whether someone has schizophrenia, but if there is some way, if the family is involved, that’s a big advantage at that particular stage because they’re going to be informed, they’re going to be more kind of, you know, plain dealers, honest brokers about what someone needs, what is looking like it’s going wrong, sorting out truth from just things that we’re not sure about. So that’s a crucial part of the puzzle, I think, in making sure something like first-step-aside psychosis would work.
But I think another problem that we’re having is, there are all kinds of mental disorders and the milder mental disorders. Adults who are having trouble concentrating more and more are convinced that they have ADHD and they need an intervention for that, and with teens it’s really just exploding, and so how you would make sure you’re targeting your intervention for a potential schizophrenia case and not another teenager who, I mean, some cases have this odd sense of pride in seriousness that they have some sort of psychiatric diagnosis. How you would square that. We’re making it harder for ourselves in some ways by just expanding the reach of diagnosis and people who are using mental health services.
Nicole Gelinas (1:13:07)
Well, thank you, Stephen, for taking some time from your early evening in Norway to be with us today. As we conclude, I might ask you, is there a one or two sentence piece of advice that you would give to the incoming mayor?
Stephen Eide (1:13:28)
I think that you should reassess the mental health part of your community safety plan and consider whether certain investments in treatment capacity that would benefit the seriously mentally ill might be a better use of the money as opposed to spending all this money on diversion services because the standard question for that is diversion to where.
Nicole Gelinas (1:13:58)
Right, and if you had a better continuum of treatment, you would not need so many street and subway interactions or ambulance calls because those people would already be in treatment after the first call.
Stephen Eide (1:14:13)
Yes, yes. It’s gonna be expensive doing this crisis response reform, non-cop response. And I just, it’s just not something I’ve ever been able to summon up that much enthusiasm for.
Liena Zagare (1:14:31)
Well, thank you very much.
Stephen Eide (1:14:35)
Thanks for having me.
Nicole Gelinas (1:14:36)
Thank you. You’ve been listening to the Bigger Apple Podcast, our fifth episode.
Liena Zagare (1:14:41)
Until next time.