Gotham Gazette https://www.gothamgazette.com/component/tags/tag/2789 Thu, 04 Mar 2021 22:48:05 +0000 Joomla! - Open Source Content Management en-gb webmaster@gothamgazette.com (Webmaster) 10 Dead, Hundreds Infected as State Psychiatric Facilities Become Another Crisis Point in Coronavirus Outbreak https://www.gothamgazette.com/state/9321-ten-dead-hundreds-infected-new-york-state-psychiatric-facilities-crisis-coronavirus-outbreak https://www.gothamgazette.com/state/9321-ten-dead-hundreds-infected-new-york-state-psychiatric-facilities-crisis-coronavirus-outbreak hospital pano

Manhattan Psychiatric Center, Wards Island (photo: @nicknormal via Flickr)


Ten people have died of coronavirus and another 193 have tested positive among the nearly 3,500 residents living in state-run inpatient psychiatric facilities, according to officials, making them one of the hardest hit institutional settings per capita in New York State. Another 283 staff that work at the state's 23 centers have tested positive for COVID-19, which has killed well over 13,000 people across the state.

After inquiries, the information was provided to Gotham Gazette on April 14 by the state Office of Mental Health (OMH), which runs the 23 sites. On April 17, just before publication of this story, OMH said it did not have any new numbers to share.

The centers are home to people with the most severe mental illnesses, who cannot manage their symptoms alone, and are proving to be particularly fertile settings for the virus' spread. They are experiencing exacerbated risks, similar to other congregate settings like jails and nursing homes, which have thus far received virtually all the attention.

Testimony from psychiatric center staff, labor union leaders, and an elected official with oversight of the centers paints a picture of sites where patients continue to gather in groups and staff lack the personal protective supplies needed to limit exposure to the coronavirus, where even basic hygiene and space to quarantine positive cases is lacking. Experts are concerned that the potential for violence among residents, already high, is heightened as they respond to life under the austere conditions of a societal lockdown.

Officials at OMH say the agency has taken precautions to protect residents and staff from the virus, but frontline workers say they have seen few changes on the ground. Union officials representing the workers said they are considering legal action to protect their members.

"There is a degree of fear and uncertainty amongst our workforce as well as, I think, amongst the patients," said Randi DiAntonio, vice president of the Public Employees Federation (PEF), a union representing thousands of healthcare workers in inpatient facilities. "We want to provide the services but we want to be safe and we want the right equipment. We don't want to be going into places when it's not absolutely necessary and critical and we want to be heard."

OMH did not provide information on coronavirus deaths among its staff. In response to an inquiry about a tip that an employee at Manhattan Psychiatric Center had died of COVID-19, spokesperson James Plastiras did not deny the fatality, but wrote: “OMH is prohibited by State and Federal privacy laws from providing protected health information.”

When asked, OMH also did not provide a breakdown of the patient deaths and positive cases by facility or county.

Based on confirmed cases, the psychiatric center coronavirus figures represent an infection rate twice that of nursing homes, and a death rate four times greater than in New York City jails, two settings that have been the focus of significant public attention, as their populations live in crowded spaces, sometimes against their will, and are often more likely to be killed by the virus.

Governor Andrew Cuomo and Mayor Bill de Blasio have each, in the face of public pressure, supported to varying degrees reducing the populations in other congregate living sites and taking stricter precautions to protect the people living in them. Cuomo has faced intense pressure to release more prisoners using his powers of clemency.

But staff and union leaders have reported "business as usual" in psychiatric centers with group therapy sessions of up to 20 people and residents gathering at mealtime in a single large dining room. Health-care workers often see patients with no protective face coverings as they continue to provide support for dozens of residents in shifts of eight to twelve hours.

"In most of the facilities patients were sitting right on top of each other," said Darlene Williams, an occupational therapist at New York State Psychiatric Institute in Washington Heights, of the group sessions that continue to meet during the pandemic. She is a 40-year veteran of the state's inpatient centers and a regional coordinator for PEF members in downstate facilities, including some of the largest in the state, like Manhattan, Bronx, and Kingsboro Psychiatric Centers.

"Somebody is going to have to die and then maybe a change will happen," she said. "I had one co-worker just tell me three days ago, 'Darlene, I don't want to die because I had to come into work.'"

In response to the outbreak, Plastiras said OMH has taken steps to ensure the safety of residents and staff, including restricting visitors except in certain cases for children, and during discharge. The agency is no longer congregating people in groups and that clinicians and staff are providing services via video and phone whenever possible, he wrote in an email to Gotham Gazette.

"OMH is taking every precaution to protect our staff and the people we serve while we continue to provide essential behavioral health services,” he wrote.

But Williams says at the Psychiatric Institute, which is attached to Columbia Presyterian, group sessions have only been reduced to no more than five patients, and that at other larger institutions in the city the sessions continue without distancing of at least six feet between individuals, as recommended by public health officials. OMH may issue directives, she said, "but that information doesn't trickle down all the way into facilities."

Protective Precautions
Workers in OMH facilities are expressing concern that they have not been given the proper protective equipment to keep themselves and the residents safe. In emails among employees at several psychiatric centers reviewed by Gotham Gazette, workers shared with one another heartbreak and extreme duress at having to work with patients who are ill and dying without personal protection.

"We were begging, begging OMH to make sure that we could wear surgical masks because we were still so close working together, employees along with patients," Williams said. She added, if it was not for Wednesday's executive order requiring masks in public at all times, "we still wouldn't be wearing masks."

In an April 7 letter to OMH Commissioner Ann Marie Sullivan, State Senator David Carlucci, a Rockland County Democrat and chair of the Senate’s mental health committee, raised alarms about conditions at an inpatient facility in Sing Sing Prison jointly operated by OMH and the state Department of Corrections and Community Supervision.

"[T]he deteriorated mental health of many of the patients in the program have prevented them from abiding with recommended hygiene practices…,” he wrote. “Despite these concerns, the Sing Sing ICP has not been provided with any hand sanitizers, cleaners, nor protective supplies."

Plastiras said OMH is working to procure and distribute personal protective equipment from available sources in accordance with CDC and state Department of Health guidance.

Staff aren't the only people in need of protective supplies, according to Williams. "The patients are also frightened because a lot of them this is their home and we're coming in and bringing in the virus. A lot of the patients are afraid, 'what will happen to me if I do get the virus?...where am I going, who is going to look after me?'" she said.

The residents of state psychiatric centers have substantial mental health factors that make it difficult for them to live on their own and meet their own daily needs. Many suffer from severe depression, delusions, bipolar disorder, and schizophrenia.

Patients may check into an inpatient facility voluntarily, but often people wind up admitted against their will after being seen in a general population hospital or other clinical setting and deemed by psychiatric doctors to be a danger to themselves or others.

Like other congregate living situations, state psychiatric centers are susceptible to unique consequences of the current coronavirus crisis. In addition to needing round-the-clock staffing, treatment for residents typically requires regular therapy, medication, and evaluation, as well as the structure and routine of life in an institution. Patients frequently have additional medical complexities that may make them more susceptible to the virus and patients may not be inclined to adhere to public safety guidelines.

"Our members, they care about this work and they want to do what's right for the patients,” said DiAntonio, the vice president of PEF. “And we recognize that there is a delicate balance between taking care of people that have high needs and that are going through real disruption, but also keeping people safe."

"One of the biggest issues we had with OMH is they made everybody ‘essential’ and refused to allow any remote working," DiAntonio told Gotham Gazette. "I've worked in facilities, I get that there are things that are hard to do from a distance. But again we are talking about a temporary situation that really may make a difference between life and death."

Plastiras said OMH is no longer holding non-essential trainings, though PEF leaders say they are still taking place. Workers are also afraid of what they have described as substandard quarantining procedures for patients who have tested positive for COVID-19.

Psychiatric wards in the past had isolation rooms for patients with infectious diseases but over the years facility budgets have been reduced and the quarantine rooms have disappeared, according to Williams, the occupational therapist at the Psychiatric Institute in Washington Heights. When a patient -- typically two to a room -- tests positive, their roommate is removed, she said, but the air is still circulated throughout the entire unit.

The union has struggled to get information on positive cases and deaths of patients and its members. "They are not openly sharing that. We finally were able to get them to make sure quarantine notices were being sent to employees if a home or location was under quarantine or there was a suspected case but for the longest time we were not getting that notice. They just started this week," DiAntonio said.

As the Times Union first reported, the New York State Correctional Officers & Police Benevolent Association has filed a complaint with the state and plans to go to court over conditions for its members working in the Central New York Psychiatric Center.

"The health and safety of our members is our number one priority. We are considering any and all actions, including legal action if necessary, to ensure their safety," wrote a PEF spokesperson, in an email to Gotham Gazette.

More Like a Hospital Than a Nursing Home
Reports from several sources indicate public health officials have treated OMH facilities, themselves hotbeds of coronavirus infection, more like overflow for overburdened city hospitals than like the homes of vulnerable populations.

According to DiAntonio, they have become overcrowded in recent weeks as hospital psychiatric units seeking to free up precious bed space for COVID-19 cases transfer to the facilities patients who cannot be discharged on their own or to a caregiver.

The Office of Mental Health did not respond to inquiries about how much the inpatient population has grown since the coronavirus outbreak began, but Plastiras said that 65 new employees had been hired in the last three weeks. The screening process for patient admissions has been "enhanced," according to Plastiras, but he did not elaborate on what the new protocol consists of.

The state Department of Health, which is coordinating the state's hospital system, did not directly respond to questions about patient transfers to OMH facilities, but a spokesperson for New York City Health + Hospitals, the city's public hospital system, confirmed that psychiatric patients that were not ready to be discharged were transferred to state psychiatric centers.

In a March 30 letter, PEF President Wayne Spence wrote to OMH Commissioner Sullivan imploring the agency to adopt a quarantine plan for patients transferred from coronavirus "hotspots" in hospitals to psychiatric centers, including isolation for the 14 days estimated to be the virus' incubation period. PEF representatives say quarantining protocols still do not include a full 14-day isolation.

On April 2, Dr. Brian Belfi, executive director of Kirby Forensic Psychiatric Center on Ward's Island, sent an email to staff saying the center would soon be taking admissions from female units on Rikers Island. "These are inmates that would have historically gone to Elmhurst which is overburdened with COVID," read the email, which was reviewed by Gotham Gazette.

Williams said there was a push by OMH to discharge patients from psychiatric centers but it was largely unsuccessful. "The movement of patients was a lot easier before the pandemic," she added. "Admissions are still happening but patients aren't going anywhere."

Meanwhile, a five-story addition to South Beach Psychiatric Center on Long Island, which was set to open this month to replace an old building damaged by Superstorm Sandy, is now being used to treat coronavirus patients and will no longer house psychiatric residents, according to Plastiras.

Element of Violence
It isn't all business as usual in the pandemic. Major disruptions in residents' routines are taking place as family visitations are cut off, favorite staff members fall ill, and off-campus movement is restricted. "It's sadder on our unit than it used to be. For a person who has been there for so many years and has seen so many things -- I've never seen anything this depressing," Williams said.

The limitations mean some required therapy sessions or family visits cannot take place, which for some is a barrier to being discharged. "We have some places where people are pissed because ‘I'm not getting out as quick’," she said.

OMH has one of the highest rates of workplace violence of any government agency. According to a state Department of Civil Service report, "patient restraint" is a leading cause of workers' compensation incidents, accounting for roughly 9 percent of the total in fiscal year 2019. The report says the job titles with the three highest workplace incident rates were Correction Officer, Direct Support Assistant, and Mental Health Therapy Aide. The two facilities with over 500 employees that had the highest rates were Mid-Hudson Psychiatric Institute and Bedford Hills Correctional Facility.

Williams says physical altercations are not uncommon in inpatient psychiatric settings, but the current strain on daily life may push it to extremes. "It puts staff and our patients at risk because now violent outbursts can happen" more easily, she said.

"I think that's also probably one of the reasons that OMH is so resistant to changing things that might keep employees and patients safer because they do worry that too many changes will create more problems," said DiAntonio, the union vice president. "However...I think there are a lot of things that are in between having no services and having services provided in an alternative way."

"Radio Silence"
Inpatient psychiatric centers have gone entirely unmentioned in the daily briefings held by Governor Cuomo and Mayor de Blasio, where they’ve fielded many questions about other vulnerable populations, including those in nursing homes and correctional facilities.

"In the realm of this specific branch of healthcare delivery it just feels like there's radio silence from providers, from the press, and just I think the general public awareness," said Dr. Julia Eilenberg, a psychiatrist who runs a private practice in Rhinebeck, New York.

"I have a patient who I just spoke to today who is profoundly depressed," she said. "And I'm trying so hard to keep her from needing to be admitted somewhere because I just don't know enough about where it would be safe from an infectious disease standpoint for her to go."

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by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

Read more by this writer.

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10 Dead, Hundreds Infected as State Psychiatric Facilities Become Another Crisis Point in Coronavirus Outbreak Fri, 17 Apr 2020 04:00:00 +0000
How the City's New Jails Plan Accounts for Those with Serious Mental Illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness Rikers Island inmate detainee

(photo: Michael Appleton/Mayor's Office)


In an historic vote last month, the New York City Council approved the plan to close the Rikers Island jail complex and replace it with four borough-based jails by 2026. When the Council voted through the plan, estimated at $8.7 billion in new construction costs, it also announced, with Mayor Bill de Blasio, a $391-million package of citywide and community investments in criminal justice reforms and initiatives to responsibly accelerate the reduction of the city’s jail population.

For city officials, one of the most complex issues they face is ensuring that the new system is less punitive and more rehabilitative, particularly for the 43% of incarcerated individuals who suffer from some form of mental illness. Experts and advocates say the plan is taking an appropriate approach to that issue but also insist that it provides a novel opportunity to rethink how the criminal justice system deals with the mentally ill, especially those suffering from more acute problems.

Given that one of de Blasio’s signature programs as mayor is the ThriveNYC mental health “roadmap” spearheaded by his wife, Chirlane McCray, the mayor’s approach to services for those with severe mental illness, particularly those who wind up involved in the criminal justice system, has been the source of intense scrutiny, again heightened as the new jails plan was crafted.

With most major crimes at or near record lows in the city and recent shifts in law enforcement and prosecutorial policies, particularly around non-violent offenses, the number of people incarcerated in city jails has been consistently declining. That drop has been so sharp that the de Blasio administration projects the average daily jail population to fall to 3,300 by 2026, when Rikers is set to close, down from about 7,000 this year and aided by state bail reform that will go into effect in January.

The Rikers closure plan will involve building four new facilities in every borough except Staten Island, with roughly 885 beds each. The facilities are meant to be fairer and safer than the dilapidated jails on Rikers. Another 250 new beds will be created in existing public hospital facilities for those individuals who require continuing access to specialized medical services.

Mayor Bill de Blasio himself has acknowledged that the city has its work cut out for it when it comes to individuals with mental illness who are locked up in jails. The day after the Council’s vote, the mayor made his weekly appearance on WNYC’s The Brian Lehrer Show and a caller named Winston who was formerly incarcerated on Rikers prodded him on improving access to mental health services. De Blasio emphasized the decarceral aspects of the plan, which include greater investments in alternatives to incarceration, supervised release programs, and mental health initiatives.

“This thing is not in isolation. Six years of changing the approach to criminal justice and it’s all been consistent with reducing crime at the same time and I’m very convinced that this is the right approach,” said the second-term Democrat. “But you’re right, it will take some important adjustments and investments and getting people more access to mental health services, which is the whole concept behind the Thrive[NYC] initiative, is absolutely necessary going forward, and providing better and more consistent mental health for those who do happen to be incarcerated, which is also in this plan.”

One of the key elements of how things unfold will be the dichotomy of mental health services for those with serious mental illness who need treatment while serving jail time versus those who can be removed from or kept out of jail given appropriate treatment options and enrollment in such programming.

City Council Speaker Corey Johnson, in a statement to Gotham Gazette, said, “The time of locking people up because they're mentally ill has to come to an end. This is why we are creating new Intensive Mobile Treatment (IMT) teams to provide intensive treatment to adults with recent and frequent contact with the mental health, substance use, criminal justice, and homeless services systems. It is time to eliminate an unjust system that has criminalized mental illness and destroyed so many of our communities.” 

In a background briefing, an official from the Mayor’s Office of Criminal Justice, which took point on the jails plan, laid out the various pillars of the city’s approach. The official reemphasized what de Blasio said on the radio: that the administration’s focus is to minimize the number of people in jail with behavioral health, mental health, and substance misuse problems, and to prevent reincarceration by providing services that address their needs.

Correctional Health Services, an arm of NYC Health+Hospitals, is charged with providing medical services to the city’s jail system, from pre-arraignment through reentry. According to a H+H spokesperson, roughly one-third of the 43% of detainees who receive a mental illness diagnosis have severe mental illness – schizophrenia, bipolar or depressive disorders, and post-traumatic stress disorder – making up about 16% of the total jail population. For a population of about 7,000 detainees, that means just over 1,100 people with serious mental illnesses at any given time.

Currently, each jail has what H+H says is the equivalent of an outpatient clinic. For detainees with serious mental illness, intellectual disabilities, or who might be more vulnerable in the general jail population, there are 18 so-called mental observation (MO) units across the 10 jails and Horizon Juvenile Center. There are also inpatient psychiatric beds at Bellevue Hospital for men and at Elmhurst Hospital for women, all of whom are considered part of the city’s jail population while being treated.

The community investments package that the City Council and mayor agreed to includes an expansion by Correctional Health Services of two programs that provide discharge and reentry services to the formerly incarcerated, the Community Reentry Assistance Network (CRAN) and Point of Reentry and Transition (PORT) programs.

Though the city is hoping for the best, it is planning for the worst. About 40% of the beds in the new borough jails will be therapeutic housing units to account for the percentage of the jail population that suffers at least some kind of mental illness.

The city plans to reduce the population through various efforts, including implementing recommendations from the city’s Crisis Prevention and Response Task Force announced last month, which will change how police respond to people experiencing mental health crises. The city is putting $23 million in total towards those recommendations by 2023, which includes adding four Health Engagement and Assessment (HEAT) teams of clinicians and peers who have experienced mental illness to handle non-emergency responses, and six more mobile crisis teams (mental health professionals who respond to calls to the NYC-WELL hotline) to conduct home visits and respond to urgent situations.

These programs aim to ensure that people suffering from mental illness do not wind up in jail, or back in jail as the case may be.

Additionally, the city is investing $11.2 million to add 380 beds of “justice-involved supporting housing,” for a total of 500 across the city, and is increasing the number of post-release transitional beds for those with mental health needs and a history of homelessness to 500 with a $25 million investment.

About $27 million in new funding will go to mental health services (for a total of $37 million) through various programs. And the Council also passed the Get Well And Get Out Act, which will allow those with serious mental illness to push for their release from custody if they improve with treatment.

But the official from MOCJ conceded that there will inevitably be individuals with serious mental illnesses in jails, despite the city’s best efforts to reduce that population, which has stubbornly hovered in the 10-15% range even as the overall numbers of detainees have fallen. Almost all of the people held in city jails are either awaiting trial, locked up due to a parole violation, or serving sentences of under one year.

The new borough facilities and the Rikers plan account for the fact that some detainees will suffer from serious mental illnesses by expanding two key programs that address this population: Clinical Alternative to Punitive Segregation (CAPS) and Program to Accelerate Clinical Effectiveness (PACE).

The Council’s agreement with the mayor includes $12.8 million to double the number of existing PACE units by the end of the current fiscal year. The city has yet to decide the breakdown of those units in the borough facilities, the MOCJ official said.

The 250 new Outposted Therapeutic Units outside the jail system, however, will be dedicated to those individuals who have some form of substance abuse disorder, mental health or behavioral health issue as well as a complex need for medical care. The MOCJ official said they had identified a gap in the current continuum of care for these detainees, who don’t necessarily require inpatient hospitalization but benefit from proximity to specialized care. They can spend hours going to and from hospitals for even the shortest of check ups with specialists. 

The city is currently in the process of identifying vacant sites for those units and has contracted Lothrop Associates to conduct a feasibility study that is expected to be concluded by the end of the year, the MOCJ official said. The study will help determine the costs and needs of the new facilities and the city will then put out solicitations for redesigning the new spaces to accommodate incarcerated individuals. The project is separate from the borough-based jails plan and the official said it would likely move much faster since it would not require approval through the city’s land use process.

Insha Rahman, director of Strategy and New Initiatives at the Vera Institute, said a larger goal of the Rikers closure plan should be to minimize the harm that jails do to inmates, not just those with mental illness.

“If we're going to say, ‘We are still going to have incarceration in this city,’ which we are, for the foreseeable future, 5, 10, maybe even 20, 30 years from now, we should be constructing these new facilities as buildings first, and then outfitting them to be places of incarceration so that they're not built with just incarceration and jail design front and center,” she said in a phone interview. 

She cited the example of jails in countries like Germany and Norway. “To the extent that we're thinking about how do we address people's underlying needs and how do we provide therapeutic care and counseling for those who are in custody, anything that looks fundamentally like a jail is going to inflict some amount of harm and trauma,” she added, insisting that the city should look not to prison architects but to behavioral and mental health experts for ideas for the new jails.

Rahman also urged the administration and Council to invest further at the community level in permanent affordable housing, community-based treatment and counselling that can preempt interactions with the criminal justice system.

A stark reality that the city faces is dealing with those individuals with serious mental illness who pose a threat to themselves and others, a concern that was brought to the fore last month when a mentally ill homeless man killed four men sleeping on the street in Chinatown. It prompted the city to review how it implements Kendra’s Law, which allows courts to mandate involuntary “assisted outpatient treatment” for such individuals. That review is meant to be completed by next week. The number of individuals ordered into treatment under the law was 2,476 in fiscal year 2018, down from 2,517 in fiscal year 2017 but up from 2,368 in fiscal year 2016 and 2,176 in fiscal year 2015, according to data provided by the de Blasio administration.

Rahman warned against harsher enforcement of the law. “I think enforcing Kendra's Law more strongly is not necessarily going to get us fewer people in our jails that have serious mental health needs,” she said. “I think the most important initial response is more community-based treatments and figuring out how can we actually resource families and neighbors.”

There is some disagreement on that front, however. D.J. Jaffe, executive director of Mental Illness Policy Org, criticized the city’s ThriveNYC mental health initiative and called for an expansion of Kendra’s Law in an op-ed in the New York Daily News following the Chinatown murders.

Jaffe argues the City Council should require “the city’s Department of Health and Mental Hygiene to start evaluating all seriously mentally ill people being discharged from Rikers; all seriously mentally ill leaving shelters; and all mentally ill patients being discharged from city hospitals after an involuntary commitment. Those are the three highest risk groups; evaluate them all to see if they are eligible for Kendra’s Law and get them into it if they are.”

Minister, Dr. Victoria A. Phillips of the Urban Justice Center Mental Health Project echoed Rahman’s view, but also stressed that the new jails should prioritize interactions between detainees and health care workers, rather than with corrections officers.

“Behind correctional walls, it’s never the health staff that takes the lead, and I think the Department of Corrections has shown itself to be unable to change its culture of violence,” she said, pointing to the most recent report by a federal monitor with oversight of the city’s Department of Correction, which showed that use of force by corrections officers has risen dramatically while the jail population has dropped.

Former New York Chief Judge Jonathan Lippman, who led the independent commission that proposed the leading Rikers closure plan, praised the approach the city is taking, while acknowledging that the overarching objective is to keep people with mental illness out of jails. “If you have people who the system decides to incarcerate, then you have to deal with that,” he said in a phone interview. “In an ideal world...people who have serious problems with mental health should get help and not be incarcerated. But, you know, we don't live in the ideal world.”

[READ: 'No One Should Enter the Criminal Justice System for Something Related to Mental Illness']

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by Samar Khurshid, senior reporter, Gotham Gazette
     

Read more by this writer.

Note - This article has been updated. 

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How the City's New Jails Plan Accounts for Those with Serious Mental Illness Thu, 07 Nov 2019 05:00:00 +0000
‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc first lady chirl mcc first

Chirlane McCray on Rikers Island (photo: Michael Appleton/Mayor's Office)


A rising number of 911 calls to report emotionally disturbed persons, several fatal encounters between police officers and people with serious mental illness, and an increasing percentage of seriously mentally ill people among those detained in city jails have all raised questions about how New York City and State provide care for those suffering from the most serious mental illnesses.

These questions and concerns don’t have easy answers. The city’s public hospital system, NYC Health + Hospitals; the mayor’s mental health care roadmap, ThriveNYC; services from the city’s Department of Health and Mental Hygiene; treatment within the city Department of Correction; private clinics; mental health shelters; and more combine to create a complex and stratified framework for treating those with a serious mental illness (SMI).

For some, much of what is at times called a crisis of treatment for those with serious mental illnesses like schizophrenia can be traced to the trend whereby the state closed down psychiatric hospitals with many thousands of inpatient beds while requisite treatment systems were not put into place to help people who would no longer be institutionalized, many of them cycling through the criminal justice system and inappropriately receiving their best mental health care while in jail.

There is insufficient use of mandatory outpatient treatment, some critics of the city and state say, with significant recent criticism also aimed at Mayor Bill de Blasio and First Lady Chirlane McCray over how resources have been allocated in their signature ThriveNYC program. Meanwhile, others have focused on questioning that police officers with guns are often first responders to people experiencing a serious mental health crisis, and those critics have been successful to some extent in getting protocols changed, though they say there is clearly more to do.

Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, says he’s troubled by the gaps in treatment and looking for new answers that would require the city and state to work together.

“The problem with the current mental health system, from my point of view, is for people with serious mental illness, the people we most worry about, the people we sometimes see on the subway or sitting on the bench, that right now there is nothing in between acute hospitalization and traditional outpatient care,” he said in April during an appearance hosted by the Citizens Budget Commission (CBC), a nonprofit think tank.

During an interview after the CBC event on the What’s The [Data] Point? podcast from CBC and Gotham Gazette, Katz was asked for more on his view about how to fill that gap.

He said H+H is working with the state on fixing a system that “drops off too precipitously.” Katz said he was in discussions to create programming to increase services for those who don’t qualify or don’t want to be admitted for inpatient care at a hospital but don’t receive enough treatment or care in the current outpatient system.

“We know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail,” he said on the podcast. “They don’t need to be locked up but let’s provide them a positive residential program that they want to stay at because it’s better than shelter and it’s better than the jail when we know that there are people who get arrested in order to be taken care of in jail.”

Over the course of months since Katz’s April comments, Gotham Gazette reached out multiple times to New York City Health + Hospitals and the Mayor’s Office but didn’t receive any further details on Katz’s vision for the program or whether there are ongoing discussions to make it a reality. State law and the state Office of Mental Health (OMH) have near full authority over the types of mental health treatment options allowed throughout the state, and are essential to the discussion, as Katz indicated.

In a statement to Gotham Gazette, a spokesperson for the New York State Office of Mental Health said, “as New York State continues to transform its mental health system to serve more individuals in the least-restrictive setting possible, we are expanding our reach through community-based services. These treatment models allow people to stay in the communities where they are best supported.”

Serious mental illnesses are not the types of mental illnesses and mental health issues that plague a little under 50 million Americans; according to the National Institute of Mental Health, about 4.5% of American adults have a serious mental illness -- meaning roughly 239,000 New Yorkers based on population statistics.

The three most common SMIs are schizophrenia, bipolar disorder, and major depression – less severe depression and anxiety are not categorized as serious mental illnesses although both the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) agree there is some ambiguity in the cut-off line for what’s considered a “serious” mental illness. It’s also important to note that there are complications with the term “serious mental illness”; it is not a diagnosis itself, but a level of disability or a threshold for having a particularly significant and debilitating mental illness.

In asking how New York treats those estimated 239,000 New Yorkers, there are the unavoidable questions of where they can and should be treated, as Katz indicated. Back in the early 20th century, many people with SMIs were admitted into state psychiatric centers, more commonly known as “insane asylums”; however, over the past 80 years there has been a major shift in placing those with serious mentally illness into inpatient treatment.

In the 1950s, New York began deinstitutionalization – a shift from inpatient care (a patient admitted into a hospital full-time) to community-based outpatient care. According to a 2018 report by Manhattan Institute senior fellow Stephen Eide, the process of deinstitutionalization continues to this day but may have gone too far. According to the report, the city’s public hospital and health care system, NYC Health + Hospitals, is the leading provider of inpatient psychiatric care in the city with only 1,218 beds dedicated to adult inpatient psychiatric care, representing 48% of adult inpatient beds in the city. State psychiatric centers in the city account for 1,058 adult inpatient beds.

ThriveNYC, led by McCray, has come under fire on multiple fronts, including general money mismanagement and lack of clear outcome-tracking, but also for how it helps -- or doesn’t help -- those with serious mental illnesses. During a City Council budget and oversight hearing on March 26, McCray was pressed on the issue several times, including pointed questions about how much of the ThriveNYC budget is dedicated toward treatment for those with SMIs.

At one point she said, “All of Thrive is really focused on the seriously mentally ill,” but she and others who testified about the program eventually offered more clarity.

Thrive, which is called a “roadmap” and spends around $200 million per year on programming and coordination, does include services solely focused on those with serious mental illness, but its main objective is to plug gaps of already existing services run by H+H and the city Department of Health and Mental Hygiene (DOHMH), while reorienting health care to always include mental health care and extend awareness and treatment into all of the city’s communities.

“Thrive is dedicated to prevention when possible, early prevention, treating people in crisis, and making sure people are stabilized when they do reach a crisis point,” McCray said. In arguing that all of Thrive is aimed at serious mental illness, she argued that untreated lower-level mental health issues can spiral.

Thrive, in the context of treating those with SMIs, is criticized for focusing more on mental health rather than mental illness; most of its 54 initiatives are focused on combating stigma, the negative factors that can lead to mental illness, and encouraging people to spot mental health issues in others and themselves, and to seek help.

In a May op-ed in the New York Post, DJ Jaffe, the executive director of Mental Illness Policy Org, and Eide of the Manhattan Institute called for the reallocation of ThriveNYC’s entire budget to focus on those with serious mental illness. They offered specific ways in which to redirect funding into different programs, such as enhancing existing crisis intervention teams, creating an office to exclusively manage the use of Kendra’s Law in New York CIty, and promoting supportive housing for homeless people with serious mental illnesses.

“The most serious cases are the ones most likely to become homeless, arrested, incarcerated, hospitalized and violent if they go untreated,” they wrote. “Yet Thrive virtually ignores this group in favor of people with less severe illnesses.”

Susan Herman, the recently-appointed executive director of ThriveNYC, said during the March testimony, “we are filling strategic gaps and piloting innovative programs for the seriously mentally ill to be able to work with people so they can stay in community by connecting them to services, by helping them connect or reconnect to treatment. We’re helping people both before crisis and after crisis.”

For example, McCray said in an op-ed in New York Daily News that Thrive adds $30 million of funding (about 15% of its budget) to the $300 million the Department of Health and Mental Hygiene already spends directly to help people with SMIs.

“Thrive-supported programs are designed to enhance and complement these existing services, not compete with or replace them,” she wrote.

For someone who voluntarily requests care, they can go to a public hospital for informal short-term hospital care as well as traditional outpatient care. The average stay for someone hospitalized for mental illness is 11 days, according to the New York City Department of Health and Mental Hygiene.

Outpatient care -- preferred by many for its community-based nature -- consists of things like meeting with a therapist or a psychiatrist and getting medication prescribed. Influential 1999 Supreme Court case Olmstead v. L.C. ruled public entities must provide community-based services to those with mental illness whenever possible.

“Lots of people have schizophrenia,” says Dr. Gary Belkin, Executive Deputy Commissioner for Health and Mental Hygiene in the city's Health Department and Chief of Policy and Strategy of ThriveNYC, in a phone interview. “The vast majority don’t end up on the street untreated and that’s because there are things that happen earlier, things that Thrive is working on – getting better care connections, having many points of contact, opportunities for family/friends to bring them mobile help."

Thrive has Assertive Community Treatment (ACT) teams dispatched around the city, often in mental health shelters, to treat people with serious mental illness. There are at least 50 ACT teams in New York with the capacity to serve 3,500 people at any time, according to Herman’s March 26 testimony. Thrive also created intensive mobile treatment teams that mostly go to shelters and provide treatment for homeless people. These outreach efforts mostly help people with outpatient care, but can lead to more intensive intervention, though it is very rare for judges to order people into inpatient hospitalization in New York.

Some of these efforts will now be part of ThriveNYC’s recently-announced outcome-tracking procedures, announced in late June.

The key questions, it seems, are whether Thrive’s efforts and the increased emphasis on outpatient programs on the state level -- perhaps including what Katz of H+H said he’d like to see -- can successfully fill gaps left by deinstitutionalization, while creating a more humane care system, and reduce threats posed by those with serious mental illness to themselves and others.

Deinstitutionalization in New York has been drastic. According to Eide’s report, as of November 2018, the average daily number of people in New York state adult psychiatric centers was 2,267. In 1955, there were over 93,000. Even in just the last four years, the number of state inpatient psychiatric beds -- in other words, the capacity for inpatient care -- has dropped by 19% statewide, from 2,866 in 2014 to 2,335 in 2018.

The drop in average daily patients and inpatient beds has coincided with an increase in the number of seriously mentally ill homeless people in New York and the proportion of inmates with a serious mental illness diagnosis in city jails.

According to Eide’s findings, there are more psychiatric beds in New York City mental health shelters than the number of psychiatric beds in state psychiatric centers and Health + Hospitals facilities combined.

Supportive housing, which provides housing and social services for those with serious mental illness, is also seen as a key tool. There are currently 52,000 units of supportive housing statewide, half of which are funded by the state Office of Mental Health (the other half don’t necessarily serve those with mental illness). Supportive housing, which is built and funded by both the city and state, sometimes in conjunction, is typically run by nonprofit providers who provide onsite mental health care, medication delivery systems, and more.

According to testimony given in a May City Council hearing by the Supportive Housing Network of New York, there are around 33,000 units of supportive housing in New York City. Amid calls for more units, both Mayor de Blasio and Governor Andrew Cuomo have made pledges to develop more supportive housing.

In his NYC 15/15 Supportive Housing Initiative announced in November 2015, de Blasio said the city would develop 15,000 additional units of supportive housing over 15 years. Two months later, Governor Cuomo announced his plan to build 20,000 units over the same 15-year timespan. These announcements came after the two were unable to come to an agreement on what have been known for decades as “New York-New York” supportive housing deals whereby the city and state work together to develop thousands of units.

The New York State Senate and Assembly Democratic majorities see a need for more programming aimed at mental health care and housing, too. Earlier this year, the two bodies unanimously passed a bill creating a temporary commission to study what is seen as chronic underfunding for these housing programs. The commission would “provide policy guidance and recommendations relating to the adequacy of funding levels and need for sufficient staffing in all supportive housing under the auspices of the Office of Mental Health.”

According to a June 25 press release from supportive housing provider Bring It Home, “[t]he bill would prompt a study of current funding and staffing levels across the state and investigate ways the state can begin to remedy its years-long failure to adequately fund mental health housing programs.” Advocates are urging Cuomo to sign the bill so the commission can issue its report in time for the next state budget season.

Another discussion that has played out over many years, at the state level especially, is over how to treat individuals who are too sick to seek help.

Per New York State Law, the criteria to involuntarily admit someone due to mental health is fairly strict – the person can’t understand the need for care or presents a substantial harm to self and/or others, among other standards.

According to a 2015 New York City Department of Health and Mental Hygiene report, 40% of adult New Yorkers with serious mental illness didn’t receive medical treatment in the prior year.

Courts can and do order people to outpatient care: assisted outpatient treatment (AOT) is also known in New York as Kendra’s Law. Originally passed in 1999 in New York State (the first law of its kind and emulated in many other states since), Kendra’s Law allows select people close to a mentally ill person to petition the court to mandate a treatment plan for that person. According to OMH’s website, as of Monday (July 29) there were 3,109 people under active court order via Kendra’s Law, 1,377 of them in New York City.

Jaffe of Mental Health Policy Org, a staunch supporter of Kendra’s Law, estimates around 4,000 people should be in mandated treatment under the law. Critics of Kendra’s Law typically accept the principle but say it’s overly strict, such as the need to show an instance of seriously violent behavior in the last four years. Once a petition to mandate care is successfully filed, the chances of the courts granting the petition are extremely high: 90% of Kendra’s Law petitions were granted statewide from July 29, 2018 through Sunday (July 28, 2019), according to OMH’s website.

Kendra’s Law affects a very small population but has shown signs of working: the state Office of Mental Health says for someone who went through an assisted outpatient treatment program, psychiatric hospitalization was reduced by 64% after AOT, incarceration by 72%, and homelessness was reduced by 61%. Jaffe and Eide in their op-ed call for the creation (and funding) of a Kendra’s Law Office to deal solely with helping the city expand its efforts to get more people into Kendra’s Law.

Meanwhile, ThriveNYC offers NYC Well, a mental health helpline that has the ability to dispatch mobile crisis intervention teams to someone experiencing a mental health crisis. The phone line is something that de Blasio and McCray often cite in their public remarks about Thrive and the city’s efforts to improve mental health care.

Another big piece of the current picture of care for those with serious mental illnesses is correctional health services, which have been needed more and more. Although the daily inmate and detainee population in city jails is decreasing, the percentage of those diagnosed with a serious mental illness has gone from 10.2% in city fiscal year 2014 to 14.3% in fiscal year 2018, according to the Mayor’s Management Report.

Dr. Katz  said on What’s the [DATA] Point? that “In the case of correctional health…we know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail.”

One goal of ThriveNYC is to limit the number of people going to jail due to serious mental illness. The city will open two health diversion centers later this year. Announced in late 2018, the diversion centers will provide somewhere for police officers to take someone who has committed a low-level, non-violent crime but they believe is exhibiting behavioral problems due to mental health. The centers will offer mental health treatment and have overnight beds but stays will be capped at five days.

Skeptics of the idea point out that there will only be two diversion centers, one in the Bronx and one in East Harlem, and each center will only serve its specific community. Plus, the centers will have a “no-refusal” policy that could edge out those with serious mental illness if the centers are at capacity. According to Herman at the March City Council hearing, Thrive plans to evaluate the success of the two programs and possibly create more centers next year.

“We want to catch [people] before entry into the criminal justice system,” said Dr. Belkin. “Nobody should enter the criminal justice system for something related to mental illness. We should be able to reach those people so that doesn’t happen, where they can be treated and managed in a health context before they get ensnared in the criminal justice system. I think everyone wants to avoid that path."

Critics argue, as alluded to by Katz and recently brought up during a Council hearing on recidivism of those with mental illness, that mental health services outside of the criminal justice system are less robust than those offered in city jails. According to Katz, “the fact that we make it necessary for some people to commit shoplifting in order to ensure they’re in a safe place, get their meds, get their food, get their house, when we could do that so much less expensively elsewhere is really a condemnation on us.”

Another option, proposed by Jaffe and Eide, is the expansion of mental health courts, which allows judges to divert those with serious mental illness and charged with crimes to treatment instead of jail. They say current mental health courts cannot offer housing to these people, which weakens its effectiveness.

City Council Speaker Corey Johnson is attempting to prevent those with mental illness from going to jail and to ensure they get better treatment instead. In a speech on criminal justice reform on May 16 at John Jay College, he announced the Council will create a program to house 100 people with SMI caught in the criminal justice system and emphasized the 100 beds are a start, but the program will need further investment and focus to add more beds.

Johnson also pointed out how targeting the legal system can keep people with SMI out of jail; he announced the Council will fund a program to connect social workers with defense attorneys to find alternatives to prison. He also previewed the Get Well & Get Out Act, which would require correctional services staff to keep attorneys informed of their clients’ mental health.

The bill was introduced on June 13 by Council Member Margaret Chin of Manhattan and six other Council sponsors, including Speaker Johnson. The Council quickly held a hearing on the bill that was combined with an oversight hearing on recidivism rates for those with mental illness. The bill has not yet received a committee vote.

How the city handles crisis situations including people with serious mental illness has come under increased scrutiny over the last few years. According to the NYPD and an investigation from THE CITY, calls to 911 involving EDP’s, or emotionally disturbed persons, have risen from around 97,000 in 2009 to 180,000 last year. Fourteen people who appeared to be suffering from acute mental illness have been killed by police officers in the past three years.

The extent to which the city’s roughly 37,000-member police force has been trained in crisis prevention is an ongoing issue. THE CITY estimated that only about 11,970 uniformed officers had undergone crisis prevention training at the time of its March reporting.

In April 2018, de Blasio and McCray launched the NYC Crisis Prevention and Response Task Force to create a strategy to better deal with mental health crises in the city. That report was due in January and has not been publicly released. The Task Force consists of leaders from the Department of Health and Mental Hygiene, ThriveNYC, and the NYPD, among others.

McCray in her Daily News op-ed said serious mental illness and EDP calls aren’t as related as they appear.

“Unfortunately, too many people think of serious mental illness as ‘crazy people in the subway,’ or 911 calls involving emotionally disturbed persons. But not everyone sleeping in the subway or on the streets has an illness,” she wrote. “And emotional disturbance describes erratic behavior at a given time — not a chronic disease.”

In an attempt to treat EDPs, Thrive created what it calls co-response teams that proactively send a police officer with a clinician to people who have shown violent tendencies or behavioral problems in the past. The forensic ACT teams, the mobile intervention teams, and the co-response teams are all a part of Thrive’s NYC Safe program.

It’s possible that the program Dr. Katz spoke about in April -- creating a residential program for the seriously mentally ill to fill in the gaps of treatment between outpatient care, inpatient care, and prison -- is what’s called “Intensive Outpatient Treatment,” or IOT, which offers a much higher intensity of services but still in the patient’s community. Patients under IOT would visit a psychiatrist more often and for longer than traditional outpatient programs.

Already existing outpatient programs must apply for a waiver to the state Office of Mental Health for permission to offer an intensive outpatient treatment program. OMH has approved waivers for 35 clinics beginning in August 2017, according to OMH’s website (they are required by state law to publicly release waiver requests and decisions).

Otherwise, the most intensive treatment with the most consistent care can be found in hospitals, prisons, or homeless shelters.

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by Truman Stephens, Gotham Gazette

Read more by this writer.

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‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ Mon, 29 Jul 2019 04:00:00 +0000