Front pages are awash with stories about New York’s mental-health crisis and the toll it takes on patients, their loved ones and the public. Details vary, but the theme is the same. Barriers to timely treatment are too formidable — a reality all the more shocking given the billions Mayor de Blasio is spending on mental health.
For most New Yorkers, the homeless mentally ill are the face of the crisis. Chronic homelessness among those with severe mental illness first emerged as a national issue in the middle of the last century. State mental hospitals across the nation were shuttered, while funds for promised community resources languished. Patients were abandoned to jails or the streets.
Decades later, the mental-health system continues to suffer from the lack of adequate treatment beds. A 2017 report by the National Association of State Mental Health Program Directors reported a 77 percent decline in 24-hour psychiatric treatment beds since 1970. Average stays dwindled to a few days, leaving time only for stabilization of acute symptoms and bed-space for only the most dangerously ill.
Treatment is frequently stymied by administrative and legal hurdles. In cases of severe psychiatric crisis, for example, providers consistently misapply the flexible medical privacy rules in the Health Insurance Portability and Accountability Act of 1996, unnecessarily withholding critical diagnosis and treatment information from caregivers.
Compounding this shortage are preconceptions and demands imposed on patients before they can access treatment. Well-meaning ideas — such as the notion that they must first “hit rock bottom” or volunteer for treatment — can leave those too ill to seek help literally out in the cold.
Psychiatrist Darold Treffert wrote of this danger in 1973, explaining that failing to engage such individuals risked allowing them to “die with their rights on.” Authorities prized the autonomy rights of patients above all other priorities.
Recent research demonstrates the wisdom of Dr. Treffert’s concerns. We now know that this population may not choose to remain mentally ill and homeless as we would typically understand it. Instead, many suffer from anosognosia or “lack of insight” — a symptom of their illness that impairs the ability to understand and perceive the illness.
For these individuals, no amount of voluntary services will ever suffice. The city may try to persuade these desperate men and women to seek treatment but goes no further when they decline.
Anosognosia affects as many as half of those with severe mental illness at some point, rendering would-be patients incapable of seeking care. It undermines the argument that remaining ill is a rational choice, belies the notion that treatment avoidance is caused by stigma and exposes an overreliance on voluntary treatment as wishful thinking.
My organization’s September report, Grading the States: An Analysis of US Psychiatric Treatment Laws, encouraged reform of New York state law to allow treatment for people who are gravely disabled and whose illness renders them unable to take care of themselves. Alongside increasing the number and availability of treatment beds, this change would provide those most in need an avenue to access needed treatment sooner, without unnecessary delay.
Nearly every other state explicitly recognizes inability to meet basic survival needs as grounds for involuntary treatment. About a third of the states also consider inability to protect oneself from psychiatric harm. New York allows neither.
New York has much to be proud of in the city’s mental-health system. But while voluntary resources in the community are vitally important, they may not always be enough. It is neither a failure of the system nor of the patient to acknowledge this reality.
We must leverage the current crisis to reduce the suffering caused by untreated severe mental illness and ensure that mental-health advancements are enjoyed by every New Yorker, no matter how ill. Half a century after Dr. Treffert issued his prescient warning, we must do all we can to ensure no New Yorker “dies with their rights on.”
John Snook is executive director of the Treatment Advocacy Center, a nonprofit that works to eliminate barriers to treatment for people with severe mental illness.
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