In December, a federal judge declined to block New York Mayor Eric Adams’s plan to allow police to involuntarily hospitalize unhoused people with mental illness pending a trial. Adams argues that overly strict interpretations of New York’s Mental Hygiene Law have left police, city workers and clinicians unsure if they are able to involuntarily hospitalize individuals with severe mental illness (unless they represent an imminent threat to themselves or others). As a result, most unhoused people with such conditions are left without structural support, suffering from starvation, freezing temperatures and untreated psychoses.
Adams asserts that by shifting the definition of “danger to oneself” to include a broader inability to care for one’s own basic needs, city workers can begin creating a pathway that leads from homelessness to mental health treatment. Adams’s plan calls for “intensive training” for first responders working with people with severe mental illness, enrolling homeless individuals in Medicaid and utilizing Kendra’s Lawto mandate outpatient care for individuals who are forcibly hospitalized.
Adams sees himself as having a “moral obligation” to revamp the city’s mental health care system and help the several thousand peopleestimated to live on New York City’s streets and subways. Yet, however well intentioned, his proposed policy resurrects a historical practice with a long, dark past. In fact, Adams’s plan is a direct echo of 19th-century ideas about “curing” mental illness, even if through forced medical treatment. Examining the past implementation of these ideas shows that involuntary hospitalization ended up functioning more as a way of removing those with mental illness from society than as a way of offering them medical treatment. Adams’s policy threatens to do the same.
Beginning in the 1870s, state hospitals, colloquially known as “lunatic asylums” or “mental hospitals,” became the primary site of mental health care in the United States.
Contrary to popular depictions of mental hospitals (e.g., “The Snake Pit,” 1946; “The Bell Jar,” 1963; “Girl, Interrupted,” 1994; etc.), asylum patient populations were not primarily composed of middle-class Anglo-American women experiencing nervous breakdowns.
Instead, state hospitals became a place to merely warehouse society’s most marginalized. They were filled disproportionately with immigrants, members of the working class and ethnic minorities. In fact, in the early 20th century, New York state legislators vocally advocated for more stringent restrictions to bar immigrants with mental illness from even entering the country.
As psychiatrists gradually realized that a true “cure” for mental illness probably did not exist, the overall medical aim of state hospitals shifted from treating patients’ illnesses to housing problematic “insane” individuals. Significant majorities of the institutionalized were involuntarily committed by families unable to care for them or after encounters with law enforcement. Many patients who were involuntarily committed spent the remainder of their lives institutionalized — subject to the wishes of the hospital staff who cared for them.
With large numbers of patients institutionalized for decades, the hospitalization of new patients produced severe overcrowding by the end of the 19th century. In response, state mental-health-care systems continually expanded their capacities. Asylum populations swelled from roughly 190,000 in 1910 until peaking at more than 550,000 people nationwide in the 1950s.
By the mid-20th century, these hospitals were underfunded, overcrowded, run-down and infamous for their gruesome conditions. In mid-century popular culture, the term “mental hospital” came to be synonymous with filth, grisly medical treatments (e.g., lobotomization, electroshock therapy, forced sterilization, etc.) and rampant patient abuse.
In the 1960s and 1970s, however, activists who called themselves “psychiatric survivors” led a broad cultural rejection of involuntary hospitalization and large institutional settings for treating mental illness. These activists argued that patients could be best treated in the least restrictive setting possible, ideally within their own home communities.
Their work, along with other medical and political developments, contributed to a complete reappraisal of how to handle people with mental illness. The changes sweeping the landscape included the advent of psychotropic medications for outpatient symptom management, a 1975 Supreme Court ruling limiting involuntary hospitalization and the creation of Medicare and Medicaid. The creation of the two federal health insurance programs provided incentives for states, which up to that point had paid to house mentally ill residents in state asylums, to shift them to private nursing facilities, where the federal government would pay for their care. Most took advantage of this cost-saving opportunity.
This confluence of factors produced a bifurcated system for handling those with severe mental illness. Patients who retained family support and were enrolled in some form of health insurance were placed in private care facilities or nursing homes, or allowed to return home with long-term medication regimens. But uninsured individuals — disproportionately poor people of color — ended up on the streets, cycling in and out of prisons. In fact, jails and prisons are some of the largest mental health care providers in the United States today. This segregated system of mental health care remains the norm throughout much of the United States in 2023.
Adams’s proposal does little to reckon with the legacies of this longer history. If permanently implemented, it would empower NYPD, EMS, and Department of Health and Mental Hygiene mobile crisis teams to identify unhoused people with mental illness and force them to go to a medical facility for an evaluation if they’re unwilling to go voluntarily.
This policy risks exacerbating existing problems within contemporary mental health care, ranging from excessive force during intake to a severe lack of capacity in psychiatric units.
According to Adams, New York City police already removed some 1,500 New Yorkers suffering from mental health issues from the New York transit system last year, even without the directive in place. No estimates exist to indicate how many more people might be hospitalized if Adams’s policy were to go into effect (or how the city would prevent the directive from being misapplied to people who are simply poor and unhoused).
While we can’t know for sure what the directive’s implementation would look like, the long history of involuntary commitment indicates that the program probably won’t “heal” people with severe mental illness and may do them more harm than good.
Adams’s policy appears well intentioned, and his focus on improving safeguards and training is positive. However, the checkered history of involuntary hospitalization indicates that even when motivated by “compassion,” such programs can quickly devolve into a method of functional removal rather than a system to improve the mental health of society’s most vulnerable. Changes in the nation’s mental health care structures are long overdue. Yet, relying on a tactic with a long history of failure is a dubious proposition. Only new thinking offers the possibility of avoiding a repeat of past mistakes.