QPP 44: Stephen Eide on Mental Health Supervision

Stephen Eide discusses his Violence Reduction Essay “More Supervision for the Mentally Ill.” Stephen Eide is a Senior Fellow at the Manhattan Institute for Policy Research. He researches state and local finance and social policy questions such as homelessness and mental illness.

Audio:

https://www.spreaker.com/episode/44211234

Read his essay at the Violence Reduction Project.

And here’s the video of the podcast episode, above, just for people who prefer to watch the talking heads.

Transcript:

[00:00:03] Hello and welcome to Quality Policing. I am Peter Moskos, and I am here today with Stephen Eide, who is a senior fellow at the Manhattan Institute for Policy Research. He researches state and local finance and social policy questions such as homelessness and mental illness.

[00:00:24] And this is another and hopefully a continuing series of interviews with people who contributed to the Violence Reduction Project, which is a collection of about 30 or so essays related to the rise in violence last year in twenty twenty. And what we can do about it now to counter it, to bring down violence. And that is available at qualitypolicing.com, as is this podcast.

[00:00:55] But if you go to quality policing dot com, you can get a link to the Violence Reduction Project and the essay by Stephen, which is titled More Supervision for the Mentally Ill.

[00:01:09] Could you? Well, first of all, welcome, Stephen. And I don’t know. Can you tell me about the essay?

[00:01:15] Yeah, sure. Thanks, Peter, for the invitation. I try to organize my essay around the concept of supervision. More supervision for the mentally ill might be a way to reduce violence overall. And that’s how we would meet the overall goal of this project. When we talk about the challenge of mental illness and the challenge of how in a way that leads towards disorder and crime and in some cases violence, a lot of times we’re talking about treatment. Treatment is a medical term and studies, epidemiological studies that have done of the population have shown that the mentally ill population are go untreated at a very high rate. A very high number of people with serious mental illness do not receive the treatment that they need. That is really the ultimate goal of what we’re trying to get to with mental illness policy. But I think supervision is a concept that gets us towards treatment and maybe more meaningful in a policy sense. It’s not really a medical concept, but it’s a term that policymakers may find more useful to think about when they’re trying to get people or organized systems in a way that are more conducive to letting the medical professionals do the work that needs to be done ultimately to stabilize people with untreated, serious mental illness. So that’s why I tried to emphasize the concept of supervision as a general way of thinking about what we’re trying to do here.

[00:02:48] And do we have data on the percentage of mentally ill who do become violent on the streets? And similarly, do we have any data on the percentage of crime committed by people in crisis that have mental illness that could, in theory, be treated?

[00:03:06] Well, it’s a very controversial idea at all, I should say, just to frame a response that mentally ill people are violent at all. There’s been a movement dating back many decades to frame the mental illness challenge as a disability rights challenge. And that’s essentially a civil rights challenge we’re trying to do is integrate the disabled, mentally ill people into society. They been there long standing victims of oppression, just like racial minorities. And thus and they are no more harmful than the non mentally ill population. However, the studies that have been done that look very carefully at the mentally ill population and find them to be no more violent or or prone to criminal activity than the rest of the population often leave out population the portion of the mentally ill population that are in hospitals, that are in jails and prison and thus give an artificial slant on the the basic propensity to violence. It is certainly true that the vast majority of the mental, the seriously mentally ill population is seriously mentally ill. Population would be about four to five percent of the adult population as a whole. Yes, that population, generally speaking, is not prone towards violence. However, if you look at the untreated seriously mentally ill population, then they do seem to participate in criminal activity, in acts of violence at a rate higher than that of the non mentally ill general US adult population. About 15 percent is the figure that 15 to 20 percent of the seriously mentally ill population is incarcerated. That is that has been a figure that was persistent. High for a long time, even throughout the recent decline in the jail and prison population and studies looking at the Met. So you have a 15 to 20 percent of the incarcerated population versus only four to five percent of the general population. That suggests, I think at the very least, the involvement in criminal criminal activity, an elevated rate and an elevated way. And you could there have also been studies that have done by, for example, the New York City idea, the independent Budget Office, looking at the kind of charges that people with mental disorders are charged with versus the general jail population. And they seem to be charged with more serious crimes than the non and the rest of the population without mental disorders. So that at least a very basic way indicates that when people with mental illness don’t receive treatment, then, yeah, they’re more likely to engage in criminal activity than the rest of the population. So going to be verbose?

[00:06:12] No, no, that’s good. And I’m I’m hesitant to even frame some of these questions because mental illness is not my field.

[00:06:20] So if I say something that needs to be corrected or explained, you know, let me know because I’m asking the mental illness part of this very much as a layperson.

[00:06:33] What what is there an accepted figure or an unknown figure for whom the percentage of people incarcerated who have a serious mental illness? I know it’s high, but.

[00:06:45] Well, it can be a little bit complicated gathering those those types of statistics in a very precise way, because jails are run by counties and whenever you’re trying to gather data from local system, there is just a lot of variation and messiness across the nation as a whole. And also definitions of serious mental illness can vary. And probably in many jail systems, there’s not necessarily a great amount of diagnostic work being done. You’re also talking about a very transient population. But that all being said, I would say that 15 to 20 per cent would be a reasonable estimate.

[00:07:29] And mental illness, of course, is a broad category. Yeah, what what are the diagnoses we’re talking about in terms of.

[00:07:40] Well, when we enter in terms of the population that will end up incarcerated, I assume it’s it’s you know, I assume depression is not high on the list and schizophrenia is. But can you. Can you. Is that possible? Can you break that down at all?

[00:07:54] Yeah, the terms have changed over the years and different service systems and different levels of government are not always defining the terms and exactly the same way, which makes everything very complicated. But, you know, the term that most policymakers use is serious mental illness or severe mental illness to distinguish the especially troublesome population from people with general mental disorder, people with anxiety, people who have like hoarding disorders or something like that. The Diagnostic and Statistical Manual lists dozens and dozens of various diagnoses, but which with which are conditions that someone can be diagnosed with but live a perfectly functional, normal life. It’s not a flourishing, happy one. Serious mental illness technically means that four to five percent of the adult population, that is a subset of the broader population with some form of mental disorder whose condition is so serious that they have difficulty functioning and normal adult life. They can’t maintain regular dealer relationships with friends and family. They can’t hold down a job. They may have difficulty performing just basic daily functions. And so it’s a serious mental illness technically is defined in terms of functionality. But generally speaking, yeah, you’re talking about schizophrenia and bipolar disorder would be the two leading condition diagnoses that we’re talking about, especially within the criminal justice context, also the homelessness context. So technically, you could have other diagnoses than those in qualify and qualify as serious mental illness. But generally speaking, schizophrenia and bipolar disorder would be the two to were mostly talking about.

[00:09:47] And presumably that is both that would both be made worse and be a cause of homelessness, right?

[00:09:55] Yeah, the way I like to talk about it is people with schizophrenia are very difficult to live with. And even when they have housing in the sense that they live with their families who are trying to care for them, as many journalistic accounts of, for example, Subway Cushing’s attest that schizophrenia developed in the late teen early, early twenty years, and especially when it goes untreated, they become very difficult to manage. They become resistant to the type of restraints that their families are trying to place on them, probably often for their own good. And then there’s a break in. And I should also say that especially if you’re talking about low income communities or any family, if they’re small children around, there are other people in the family. As well, there needs to be taken into consideration. For various, it may just be impractical to try to keep this individual at home so the bond breaks and that’s in addition to, yes, there are these economic issues. You can’t hold down a job for schizophrenia. But, you know, but socially, it’s it’s a problem. And thus it’s, you know, unfortunately understandable. That’s the right word why so many people wind up on the streets in that condition.

[00:11:21] I mean, I presume that everybody who pushes someone in front of a subway train and there well, there’s certainly anecdotal evidence, but I believe there’s data to support it as it has been increasing in the past two years in New York, where since twenty 20, I assume everyone who pushes someone in front of a subway train has a serious mental problem. I don’t think it’s it’s I mean, correct me if I’m wrong. I think that’s a safe assumption. Is there something about what is it about schizophrenia that makes some people want to push someone in front of like a subway train? Like, you know, I don’t get it, obviously. What what what’s the connection between schizophrenia and sort of random violence?

[00:12:03] Well, you know, schizophrenia is a thought disorder, thought disorder. You obviously interpret the world around you in a very different way than than than other people do. It is true that that can happen in a in a somewhat, but just silly, comical, essentially harmless way. And even many people who have violent tendencies in their early when it first comes on sort of calmed down a bit in their later years, some sort of parallel to how people talk about aging out of crime. But I think that I don’t I don’t have a good medical explanation for your question, but they they interpret other. Experiences, interactions, things that people say in a way that they regard as as threatening and thus from their perspective, they need to commit certain acts from the from a from a self-defense perspective often that other people would say we’re not you know, they were not they were not in any real threat.

[00:13:23] And is this tied to hearing voices or is that a different diagnosis?

[00:13:29] Yeah, yeah, schizophrenia would be. That would be a symptom of schizophrenia.

[00:13:35] Yes, and it’s those voices are almost never telling you good things, unfortunately, which is interesting.

[00:13:44] Some some schizophrenic people can become functioning, some even high functioning. There are. But, you know, one thing that I’ve noticed is that when you talk about memoirs that people write about overcoming mental illness, there are a lot of memoirs about overcoming depression. There’s some about overcoming bipolar disorder. There aren’t a lot about overcoming schizophrenia. There are some. But they seem to be fewer in number, especially of the of the depression overcoming depression genre. So it’s a really tragic thing and it’s especially tragic for the families that have to.

[00:14:28] And is there a gender disparity? I can’t remember the statistics of offhand about the breakdown between man and woman and is there just is can treatment be effective or how often are there medicines?

[00:14:45] Are there drugs that people can take to to make things to at least mitigate things or make things better? What’s the state of medical treatment for this?

[00:14:54] Yeah, I think that I mean, any. Any competent. Leaving aside sort of a. radical a. psychiatrist types, any mental health professional, any clinician, any competent psychiatrist would recommend medication as being really essential to trying to stabilize somebody with schizophrenia, though there were generations ago hopes that there could be at some point a wonder drug of wonder cure that would eliminate this plague forever, similar to other medical advancements that were made in the 20th century. It’s never really worked out like that. And oftentimes one reason why it’s so difficult to stabilize someone is coming up with the right combination of medications takes a lot of time, a lot of guesswork and and failures. The medications often have unpleasant side effects that contributes to the difficulty of finding a regimen that will take at a very high rate many schizophrenic people. They have trouble grasping the idea that they are sick, that they do have a mental illness, and that it also makes them resistance to taking medication. And sometimes when people are stabilized and they think that they’re cured and they don’t need to take medication anymore, and so they relapse after that. So it’s very difficult work. And like I said, I think to the minute the medication portion of the treatment regimen, you know, will also interact with whatever else is going on in someone’s life, like the personality of the social worker, they they have to deal with whether they have some sort of housing, their relationship with friends and family and, you know, nonmedical treatments such as supportive employment, just something to do during a meaningful daily activities can also be absolutely crucial to just stabilizing someone, giving someone something to recover for similar to how we talk about recovering for substance abuse. So it’s a really complicated process, trying to bring someone from a state of, you know, just dangerous, florid schizophrenia to just basic stability. And, you know, clinicians will often say it’s hard to know at the beginning of that process who’s with who, who it’s going to succeed with and who it’s not going to succeed with.

[00:17:37] And I mean, the reason this relates to criminal justice, if nothing else, is looking at the Washington Post database, but now has sixty one hundred and sixty three people shot and killed by police going back, I guess, to twenty fourteen or so. But by their crude breakdown, they just have a category called mental illness. And twenty three percent of those shot and killed are categorized as.

[00:18:09] Yes. Mental illness as opposed to know or unknown.

[00:18:13] And I should mention that, of course, from someone I mean, to be categorized as mentally ill in this database means it has to be pretty visible and extreme. This isn’t a I mean, it’s mean someone has to go, man, that that guy is crazy. I mean, it’s not like they’re doing a postmortem psychological test on the person. So I would say that’s probably a pretty big undercount even. But it’s a huge number. It’s a quarter of all people shot and killed by police are known for to have mental illness.

[00:18:46] Leaving aside the difficulty in solving this problem, it still jumps out to me as well, low hanging fruit.

[00:18:51] If we’re concerned about cops shooting and killing as many people as police do, that seems like both a practical and a humane place to start. How does that link to I mean, at some point, if cops are in that situation, you know, you can say it’s too late. Yeah. But, you know, cops don’t want to be in that situation. And I can also say from my own experience years ago as a cop, the times that I found really scary were, you know, it’s one thing to talk to someone who’s angry or mad or upset, you know, and drunk or high or whatever. But sometimes you’re talking to so many realize well that there’s no connection there. Their mind is somewhere else. And then suddenly sort of reason is gone, you know, what can you do? And, you know, other than sort of back away slowly. But it’s a. It’s a scary situation for everyone involved and perhaps related to that, there have been many cases in New York in the past few years where people have both murdered other people. I’m thinking of in Chinatown the guy who killed five homeless people. And then there was another case where a guy attacked a cop with a chair and knocked the cop into a coma and was also shot and I think killed by the cop. And again, there’s confirmation bias here, so I don’t know. But in many of these cases, it seems like the family has previously tried to help that person to get them committed and the person declined that help. Do you think that is my summary accurate? I mean, do does it or is there a just sort of taking these extreme cases and extrapolating too much from them?

[00:20:37] Yeah, I looked at The Washington Post data somewhat closely a few months ago, myself as well. And yeah, if you’re talking about like about a thousand police shoot fatal police shootings a year, two hundred or two, 50 of them involve mental illness. You know, the vast majority of those were the individual was armed and he was attacking the cop. So and those types of circumstances, I don’t know how much deescalate we would expect from de-escalation tactics. But even in those cases, we do want to talk about how the mental health system allowed that situation to become so bad. I mean, because the mental illness problem has driven a lot of criminal justice reform at each stage of the criminal justice reform debate, whether you’re talking about like, you know, close rigorous bail reform at some dismantle this criminalization of mental illness problem is invoked as a justification for why we need to do this criminal justice thing. But in the mental health reform context, mental health reformers always invoke that same phenomenon the high rate of mental illness among the class rated or high rate of mental illness related police shootings as the reason why we need to do mental health reform. And I think the mental health reformers have the sounder point. I mean, if this is all if if we’re really interested in going upstream and prevent and taking a preventative approach to social policy questions, then we really need to look at mental health for not as much criminal justice reform to deal with this this problem of the criminalization of mental illness, so-called. Yeah, most people did. They had they had housing at one point. They had there at one point their bridges were not burned with their friends and family. And the situation deteriorated generations ago prior to deinstitutionalization and the dramatic reduction in the institutionalized population. What a family did when they knew they had an uncontrollable adult relative as they put them in a hospital, just like developmentally disabled teenagers were put in a home essentially for the rest of their lives. Mentally ill people were put in a hospital and often oftentimes they would live the rest of their lives. In a mental hospital, for various reasons, we decided not to do that anymore, but as a result, that thrust this huge burden on families like families are now said to be the new asylums. It’s sort of interesting to me that generations ago, when we tend to think about family structure is stronger than it is now, families relied. We’re able to rely much more heavily on the government than they can now. And the mental illness, content and context families are a little bit weaker, more unstable than they used to be. But also they have this these huge responsibilities placed on them in terms of trying to deal with their mentally ill adult relatives. So we tried to build this community services system to replace the old institutional system. For a lot of people, it is it has benefited them, but the lows are very low in terms of where this whole reform program played out.

[00:24:16] So I presume, as is often the case, Western European countries are doing it better than we are. Maybe Canada is. I don’t know. And I say that because when I’m in Amsterdam, you just there are not as many visibly mentally ill people sort of ranting and raving on the streets. What do they do that we don’t watch? I mean, it’s another way of asking what should we do? But I’m trying to say, is there is there a sort of model that, while not perfect, would certainly be a big improvement over what we have?

[00:24:53] I’m not enough of an expert on the European situation, as I should be. I would say that inpatient psychiatric in terms of measures of inpatient psychiatric beds, America doesn’t look great compared to other countries. But and I know groups in California who have think very highly of the model applied in this region, city of Trius. But I’m really not an expert on the European system to to give you a treat.

[00:25:27] And this is in northeast Italy has a model that is unique to TriWest. I’ve never heard of it.

[00:25:32] A highly regarded. Yes. Groups.

[00:25:38] How much of it I mean, got in what was the recent case with a guy who attacked the woman when the doorman was accused of not helping incorrectly, I believe, accused of not helping, but, you know, turned out that man had been convicted of murdering his mother, which is never a good sign. But I always in these cases that at least make the news, it is hard not to feel really sorry for the family that. Is trying, you know, wants to do good, presumably, and just can’t cope, I mean, that’s not their fault. Maybe no one can cope. And he said, well, if the government doesn’t step in, yeah, it’s putting families that are already stretched to the limit and very precarious situations. But I can’t help but feel that if your family gets together and decides that, you know, a member of the family needs to be committed and I want some independent judge and doctor to make sure, you know, they’re just not out to get you. But if your family says we can’t, you know, this this needs to be done. It probably should be done. Is my thought that the. That there should be a reason and that, Patricia, why commitment isn’t needed, but clearly that level of care and or commitment isn’t happening right now, don’t choose to simply decline.

[00:27:03] Right. And it has to be about, you know, when when the commitment question comes up, it’s the legal process that has to be gone through in which the individual adult has a public defender who will resist the the suggestion to to commit them. And that’s it’s a pretty high standard that’s been developed, especially in New York, imminent, dangerous to self or others. Often somebody who’s been hospitalized for 72 hours held is, you know, slightly better off than they were when they first came in. And so they don’t seem to be dangerous. They don’t meet that dangerousness standard. So they have to be out again. Another problem that families have in terms of their standing and the level of respect that’s accorded their judgment is they are barred from health information about their adult relatives through Hip-Hop law. They the medical professionals went after somebody becomes 18 are not not supposed to share that information regarding how his treatment is going with his family. Caregivers and families are find this very frustrating. And there have been efforts to reform the law to make accommodation for this particular situation. But it really has not gone as far as it needs to, mostly because of the resistance by disability rights groups who find it objectionable.

[00:28:47] And are they do those rights groups generally, are they talking about mental illness or are they talking about other disabilities?

[00:28:54] And then over the umbrella of Hippocrates applied to everybody.

[00:29:00] They’re talking about the mental illness, so the same groups that resist weakening civil commitment laws, weakening or encouraging more use of inpatient hospitalization, always the specter of the One Flew Over the Cuckoo’s Nest or Snakepit Day is all we covers. Even though we’re talking about a situation that hasn’t been a reality for many, many decades. At this point, it remains very prominent and resisting any sort of backsliding in their view.

[00:29:30] I’m sure if we did return, even in part to any sort of large, larger scale institutionalization, undoubtedly there would be scandals of abuse, know maybe not as extreme as One Flew Over the Cuckoo’s Nest. But like, you know, at some point, if you’re being involuntary committed, there is a prison element to that. Even if it’s a more benign form of incarceration, you can’t leave. Right.

[00:29:56] Right. So you could. Oh, yeah. I mean, you could argue that that of being put in when a schizophrenic person is put in jail, that’s better than if they are put in a hospital hospital. If you’re involuntarily committed to a hospital, you haven’t done anything. You’ve been charged with anything. But when you’re being put in prison, you’ve been charged with a crime and held on a pretrial detention basis in jail. Well, that’s just like anybody else. That’s the normal process that any non mentally ill person experiences.

[00:30:30] So, I mean, maybe there’s some maybe they hand out various drugs, sedatives, but whatever mental illness you have going into jail, it’s hard to imagine it getting better during your time now, right?

[00:30:48] Yeah, of course. And in mental illness, a mental hospital, you know, jail and prison reform, you know, we’re talking about like reforming the conditions and like, how nice do you want to make it? Because it is, after all, jail and prison mental hospitals can be made, you know, as nice as we want them in terms of opportunities for recreation and food and so forth. I mean, it’s a difficult environment because it’s only only the very hardest. Cases get committed to mental hospitals these days. But we have in place many regulations and just a cultural oversight that didn’t exist during the bad old days that has improved the quality of inpatient hospitalization. We also have just more money to spend on it. And this because the population is so much smaller than it used to be. The staffing ratios are higher and that’s another metric of just the quality of hospitalization. So, yes, it ultimately this does come down to how much do you trust the government agency to not some sometimes falter, allow some sort of abuse or maltreatment to occur? You know, you have to trust these systems to some degree, how much you trust them? I don’t know, but there are certain reasons to think that it wouldn’t be as bad as the Battletoads.

[00:32:23] One of the more and less extreme cases, and I want to be careful in this sort of Segway transition because I’m not implying that homeless people are all mentally ill, much less violent, but shifting a little to visit to the visible street homeless population. You mentioned before the difficulty and commitment laws, if I’m not mistaken, isn’t art doesn’t New York State have two different standards, one being the imminent threat that, say, police officers can use?

[00:32:55] But can’t doctors also commit someone for some? I don’t know what the term has been basically being dysfunctional.

[00:33:00] Not being able to take care of oneself gravely disabled is the standard that some states have. I believe the only standard. And that’s a separate one from dangerousness. Yes, but I mention that because I think it’s just dangerous to go back.

[00:33:18] When the NYPD had a homeless outreach unit before it was defunded, one of the things they would do is go out with doctors to get to have both. So there’d be a doctor there. But also, I think to have an easier or a lower standard of of commitment for people that were clearly, you know, on the street and not taking care of themselves.

[00:33:46] I mean, the idea that we should just let people stay on the street because they declined services strikes me as incredibly inhumane.

[00:33:54] And it’s a weird callousness. We’re just supposed to go, OK, they said no. So just leave them be. I don’t know that that bugs me both from a common humanity standpoint and also as a resident of the city, because, you know, if someone’s on the subway and, you know, there are other rioters, that should also be part of that policy calculus. But but looking at the person who needs help.

[00:34:19] The police would commit people to Bellevue and, yeah, and the problem at least, and I don’t know, you know, Bellevue, maybe Bellevue Hospital, this is may beg to differ, but they don’t seem interested in actually treating people. I don’t know if that’s because it’s a money issue. It’s because they’re overloaded.

[00:34:38] But they’re you know, once the once the cops bring you to Bellevue, you got a police hands and it’s in doctor’s hands.

[00:34:43] And because of Pippo, we really don’t know well, what on an individual case, we have no clue what happens. But they said the person would just be released and they would be released without any. Yeah, because of there’d be no question there would be no way to follow up on future treatment. There were no social services greeting people. So they just sort of walk out of Bellevue at some random time and. You know, and and we go, right. And so I guess, I mean, it’s just it seems it’s so frustrating from their perspective because they’re trying to do the right thing, trying to get people help. But the system doesn’t even seem to help people when they’re supposed to be getting help. So I don’t.

[00:35:30] Yeah, I mean, they write you know, most of the people on the street have been hospitalized. The mentally ill population on the street have been hospitalized at some point. But it would have been a brief duration. Yeah.

[00:35:43] Is there is there a problem in the label of homelessness? Because it implies the issue. I mean, the term itself maybe doesn’t necessarily, but it’s well emphasized housing as opposed to health. Is that a problem, do you think that homeless in the way that homeless. I don’t know. Politicians or advocates or. I don’t know or maybe I’m making a straw man argument here, but I don’t think I am. And categorizing homelessness as one primarily of housing and economic conditions is that.

[00:36:19] Oh, yeah. I mean, absolutely. Before the modern homelessness crisis emerged around 1980, the term homelessness or homeless. Didn’t have anywhere near the currency that it has now and then it developed in the early 1980s, going back to the early 20th century. We talked about tramp’s, we talk about hobos, we talk about bums during the Skid Row era. In the old days, the Bowery, we especially talked about bums, not as much homelessness. Some social researchers would use the term. It didn’t it wasn’t the common popular term and also the Kitchell umbrella term that it is now. And that was deliberate on the part of advocacy groups to force that term into the debate in order to press the case for how more more support for housing, essentially. And that that was always the basic idea for. Almost inventing the term homelessness around the time of 1980, the debate has taken a few different turns over the years. But yeah, the general goal is to increase support for more government spending on subsidized housing programs, especially. And that’s why people even now, there are sometimes, you know, as we’re like deciding that some terms are offensive. That used to be just like ordinary terms more commonly used with increasing frequency. We’re hearing the term people experiencing homelessness instead of saying calling someone a homeless person. But still they can’t break from that basic term because that would then seem to diminish the idea. That would be what’s needed above all is more housing as opposed to a more effective mental health system.

[00:38:21] Homeless has to be considered as a housing problem if you’re trying to build support for more housing and of course, as an umbrella term for most people experiencing homelessness, it is a housing problem. If you look at I mean, so but in terms and the overlap with the police and criminal justice is really a small segment of that.

[00:38:40] It’s a portion of, well, some in shelters, but a portion that we’re talking about, the street homeless of New York has roughly 80000 people in the homeless and in the shelter system. I think I’m pretty sure, you know, the vast majority of those people are housed at some level, be it in shelters or hotels or temporary housing or however, the system doesn’t deal with that.

[00:39:06] I’m not you know, I’m I’m not talking about that group, it’s an important group and, you know, and they need help and I think housing is part of the solution.

[00:39:16] But to then take people who are on the street with serious mental illness and group them with a family, you know, mom with kids who go to school every day. Those are different populations.

[00:39:28] And there seems to be a grave disservice to sort of label them with the same category, no matter what semantics we’re going to use to describe what we’re talking about, different situations and different solutions, I would think. And the umbrella term homelessness or on housing or, you know, we can play around with the language as much as we want is not the issue when we’re dealing with people with severe mental illness.

[00:39:54] I mean, just I don’t know quite what my point is other than if we were to prioritize the homeless, the housing element of it, when there’s such an obvious mental.

[00:40:06] Well, yeah. I mean, there’s I mean, there I mean, it’s it’s irritating because, I mean, having studied the history of it a little bit, as I said, it was deliberate to to try to to wrench all these different problems together under the same term. And also it points towards a different standard of success. You know, how how is the city doing these days with the homelessness problem? Generally, I would say most policymakers would say, well, how many permanent supportive housing units did you bring online last year? How much housing did you build? You have a homelessness problem. That is, you succeed in meeting that problem by by building more housing. Well, what did you do on the mental health front? Well, I don’t know. That’s what mental health agencies are supposed to do. So if you how you conceive about the problem, maybe Conceiver the problem, how you talk about it points immediately to how you’re evaluating yourself and making progress on that problem.

[00:41:04] What is the history, what happened in the 80s that contributed to the what we have today?

[00:41:11] Well, I would say deinstitutionalization played a big part of it. The institutionalization of the mentally ill started in the 1950s, but really got going beginning in the late 60s and throughout the 70s. Just just huge reduction in beds and the harder cases, not like senile old people. Those were the first people to be released from the institutions.

[00:41:32] And that was a large part of the institution. Yes, there was an old folks home for a lot of people.

[00:41:38] Absolutely. Yeah. Before we had nursing homes and the way we have them now. Yeah, the old people were put in psychiatric hospitals as much as a third at the peak, I think, and I mentioned.

[00:41:47] So a lot of people draw a direct line between the institutionalization and incarceration and there probably is some link there.

[00:41:55] But it’s not the same population we’re talking about who are by and large, we’re in the mental institutions in the 50s and 60s, in prisons in the 80s and 90s.

[00:42:03] Well, it was the old psychiatric hospitals were dumping grounds for sure, and a lot of different problems were dumped on them. And so but the hardcase population, the chronically mentally ill population, those are the ones as the pressure to keep going, pushing the census and the hospitals down. Really. Got going more aggressively in the late 60s, early 70s, that’s then right before the homelessness problem emerges in the way that we recognize it. And also that’s right before when people start talking about the high rate of the elevated rate of mental illness among the incarcerated population, there are also things going on in the way that governments paid for the stuff. Medicaid came online in the 60s when Medicaid was passed. The federal government said we’re not about to be put on the hook for these expensive failing state psychiatric systems. We will only pay for community based services. So the state said, well, OK, we can build the federal government for community based services through Medicaid. Well, then that’s put people in a system where they can we can build the federal government for that. So Medicaid also contributed in a big way to deinstitutionalization. And again, in that crucial decade of the seventies, immediately before these newer problems that we’re familiar with developed around 1980.

[00:43:33] And was part of that. Can we blame Reagan for budget cuts or is there not a big factor?

[00:43:39] Well, Reagan was president right when these bag ladies street people emerged. And in this bad recession around in the early 1980s, the worst recession since the Great Depression at that time. And so the coincidence of Reagan, the Reagan administration and the situation on the streets with created this powerful correlation and in many people’s minds, also, there was a there were there were people who were very active and effective advocates of the home of the homeless who focus their energies on Washington, D.C., particularly this guy named Mitch Snyder, the most influential homeless advocate in history. And he particularly focused his energies on criticizing Reagan. It’s totally unrealistic that a presidential administration that takes office and, you know, the very public right before people started that a presidential administration could have that immediate effect. Reagan, what Reagan did as governor of California is a different story and much more problematic. But as president, this would this had more to do with long developing problems related to the Skid Row neighborhoods lower in housing market and deinstitutionalization about that low income housing market?

[00:45:08] One of my quick fixes in my mind to the problem of a lot of homelessness is to bring back S.R.O. single room occupancy, the old fashioned flophouse.

[00:45:21] And so I was born in nineteen seventy one, I actually do remember the rise of today’s homelessness problem in the early 80s, it was visible in Chicago.

[00:45:30] People that weren’t out there before suddenly were out there. And I mentioned that in part because I think I don’t know if Americans are worse off than us, but we tend to think problems are, you know, well, they’re inevitable. Nothing we can do about it. Like, no, we didn’t it didn’t used to exist. So, I mean, I know the solution, but I know there was a there was an America in which this wasn’t such a big problem. I mean, you could say the same thing with, you know, mass shootings like this is not and we have a strange tolerance to these things, I think, which is irksome to me. But the flophouse was and I believe it was because progressives were about, you know, advocated against them where they were. They were banned. There’s a grant in New York, there’s a grandfather rule. So of like still like three left, I think.

[00:46:14] But it is actually illegal to open up a hotel geared towards cheap, barely, you know, be the lowest possible standard or a flophouse. But they do give people the door. They can lock a bathroom down the hall. And that I mean, no, it’s not a great living condition.

[00:46:37] But compared to what I mean, literally, I think on the Bowery you have it was a think a Times article and final a year or two ago. But I mean, there are literally people sleeping in the doorway of the old flophouse that they sleep inside of is that is sort of a simple solution. We could say is, yeah, we just got to bring back privately run for profit crappy hotels.

[00:47:01] Well, a lot of it depends on how our tolerance for squalid housing, you know, when the flophouses thrived, so to speak, middle class standards for housing were were lower than they are now. Just a regular working class, middle class family probably lived in a somewhat more smaller, maybe not as nice housing on average then than they do now. So what are we? And the steady march. In previous generations, housing policy was about improving quality. It’s now almost completely about affordability. There’s obviously a correlation there as general housing standards got better and better quality on average, better, better became less affordable. So we’re still struggling to square that circle. You know, very, very poor people. It’s completely uneconomical to build new housing for people with almost no income. So you have to talk about somehow letting existing properties drop down and quality and letting them operate in that way. There are certain forms of low quality housing that exists in New York City, for example, that these three quarters housing operations, they draw, especially from people coming out of prison, people with substance use disorders, they have a pretty bad reputation in this city as Detroit has not been accommodating, say, at least despite all the lessons it supposedly learned about the demolition of the Bowery. The other big advantage the Bowery had, along with all the other Skid Row neighborhoods, is that they were they were they were a whole economic order. They were sort of containment zone. And it was understood that conditions would be more disorderly there than in the rest of the city. Police, as you probably know, had wider authority to police the boundaries of those districts through the use of vagrancy law, especially. And but there were, you know, pawnshops and day laborer opportunities and stuff when homeless housing for the homeless is built. Now, it’s generally thought it needs to be somehow spread throughout. The integrated different neighborhood should bear its share for housing homeless. We would have to overcome that and re embrace this idea of a some sort of a sort of like disorder zone containment zone. And that to you know, it’s not clear how far typical city politicians are willing to go because similar with just the basic question of health and quality, like how much disorder are we willing to tolerate? But I mean, L.A. doesn’t how they do that, but without any of the housing, Skid Row in L.A. was was understood to be a containment zone approach. Yes, we will. We were going to hang on to our Skid Row district while others city. Or demolishing bears and but we’re going to we’re going to. So we’re going to just sort of harm reduction. We can’t make the problem go away. We’re going to confine it to this neighborhood. But it didn’t work in the sense that homelessness is everywhere in L.A. County. Now, the total homeless population of L.A. County that’s in Skid Row is less than 10 percent. So, yeah, you still have Skid Row in L.A., but you also have homelessness everywhere. And so it just these practical, very serious, practical barriers come up when you’re trying to re establish the old Valerie idea. I mean, scholars back in the 80s who really knew the culture of the Bowery, who had studied it. And we’re in a position to compare that with the new culture of modern homelessness. On which is defined especially by living in a shelter like what’s better, living in an old SRO or cycling in between the streets in the shelter. Seems like a lot of people prefer the S.R.O.. Yeah, one thing you could always say in favor of the flophouses, there’s there was less actual street homelessness and people had a roof in a locked door and a mailing address.

[00:51:43] Yeah, partly because they were they were not government run, which means they could enforce rules somewhat arbitrarily. I mean, this type of some you know, some some crusty old guy with a cigar and a raspy voice, you know, but, you know, there were rules and, you know, obviously some people still didn’t follow them. But for the end, evicted, kicked out. But for the people who live there, at least there was presumably problems and all a greater a certain amount of just basic safety. I mean, they weren’t getting they didn’t live at risk of getting robbed every time they went to sleep.

[00:52:16] That again, I’m a big fan of better as opposed to perfect or ideal or utopian. And it just.

[00:52:25] They didn’t have strong tenant protections. One of the things which really gave the kind of mercy blow to the old flophouses, which, as you say, hung on for a long, longer time than many people understand in the 90s was the application of eviction protections to S.R.O. tenants. And so after a certain point, like landlords, those old school landlords decided it was just so much more economical to sell their building, whether it be converted to something else that can’t operate it. So you know that tenant protections is another definition of housing quality. So would we allow these different facilities to operate where people could be evicted from without much more now, much more easily? I don’t know.

[00:53:14] So going back to your essay at. Because like we’ve talked about the problems here, the essays are, you know, cover a broad range of issue, but the one theme is they have to provide some solutions, short and medium term solutions. And you you write about supervision, so. How is that what do you mean and how is that part of the answer?

[00:53:40] Yeah, well, I think so. For people who are involved in the criminal justice system and who were, you know, this could mean community supervision. And the way that we talk about community supervision, probation style programs, you’re charged with offense and offense. That’s more serious than, I don’t know, public urination, but less serious than murder. You could be facing a prison sentence of a few years, but you go before the judge and the judge tells you if you will comply, if you will participate in this program’s requirements, you will check in regularly with your social worker. If you will submit to drug testing, we will let these charges pass. You know, New York does this with mental health court programs. We need to accept the idea that the criminal justice system can play a constructive role in addressing mental illness, that, in fact, many people in the criminal justice system probably understand mental illness better than so-called mental health professionals, because not all mental health professionals work with violent schizophrenic people. But that’s one thing you could definitely do.

[00:54:49] You can also do an interesting concept, by the way, selection, by sort of working on the other side of the.

[00:54:56] I hadn’t thought of that from you, and that’s just generally something we need to understand, the criminal justice system can be helpful. The point is not just divert people away from the criminal justice system because that’s just kids. But getting back to supervision question, we need to have more essentially supervision. So there are also forms of civil commitment, civil commitment. So you haven’t been charged with a crime, but you’re you’re having a lot of problems. And for your benefit, we need to. Apply some sort of involuntary commitment to you so that that could mean in a hospital and but that can also be used in the community through the Kendra’s Law program. Contraflow is a program of outpatient assisted outpatient commitment. So you have to regularly go before a judge. You have to check in, comply with the treatment regimen. And this is a program that so you’re not falling through the cracks when you’re in countries where we’re keeping sight of you or making sure you’re remaining stable. And this is a program that has been extensively studied and has shown that it’s very good at keeping people out of out of jails and also out of homelessness. Then we need then there could be supervision that doesn’t involve doesn’t involve the criminal justice system or courts at all, but meaning that the community mental health system, as people normally talk about that. But we need to be talking about more basically supervision of that system, because one thing that strikes me about these subway questions and these spectacular tragedies is like, I’m sorry, did some social service, what social service agency was supposed to be looking out for the state? Did they lose their contract? Who do we have any type of accountability in place to make sure that these groups that were giving huge, huge contracts to are contributing to a solution to that and maybe they have a little bit of skin in the game if these problems persist. So we need to make sure that we are requiring the mental health services system, meaning especially like nonprofit organizations, to and we give contracts to focus on seriously mentally ill individuals and exercise some sort of oversight and accountability if they’re if they’re not keeping track of it always bugs me when people when the subway pushing.

[00:57:23] Well, he slipped through the cracks. I’m like, but that implies there’s some flaws, some Metronet that was supposed to hold them. And I know there are no cracks you slip through. It’s just it’s a free fall. You know, if someone in Child Protective Services gets killed, you can say that person slip through the cracks because there’s a system and the person, you know, the kid’s being monitored.

[00:57:44] We don’t have get where are where is the accountability for any of these social service groups. And I mean, one of the things saved a lot on Twitter, but, you know, Department of Homeless Services in New York City now has a budget of about three billion dollars, and that doesn’t include other programs like Thrive NYC and write. The budget of the NYPD is less than six billion. Three billion dollars is a lot of money. Yes.

[00:58:11] And so it seems like the least we could ask in return for that is someone is accountable and says, oh, that person would put someone on a subway train like, yeah, we messed up or you know what, my bad things might happen.

[00:58:24] We didn’t mess up. Maybe it will. Sometimes it just happens. But nobody says, oh, that was our charge.

[00:58:30] Right. And that like, so where is this money going? And will somebody at least step up and say, we’re going to handle this? This is our this is our domain. And I don’t see any of that.

[00:58:44] And I wonder how much of that is, you know, bureaucratic, some of it’s incompetence, some of it’s just the nature of large bureaucracy. But then you add to that a certain amount of corruption and a certain amount of I worry that perhaps people who profit from the suffering of others, I mean, I don’t even I do mean it maliciously deep down, but I don’t even necessarily mean it maliciously that they wanted to keep they want to perpetuate the problems because they don’t actually get the incentives of the system to not encourage solutions. If you.

[00:59:19] Yeah, I mean, we all seem to be more honest about what types of mental health problems we’re trying to address. You know, programs that exist to assist schoolchildren who are bullied in schools, those are mental health programs. Those are part of the mental health system. Those are programs that are very valuable to the families of bullied youths. But they can’t really be said to be doing anything about subway trains. But there is this like eliding that goes on where people will say, well, yeah, when I’m working with children, I’m trying to prevent subway pushing. So I’m taking an upstream approach. But really, in some sense, you’re trying to work on a different problem. In some ways an easier problem. But at the very least, you can say it just a very different problem. And we need to be more sort of forthright about who really is working on subway pushing and not postpartum depression for homeless women, anxiety for school children, things like that is they’re just entirely different. This is the Thrip NYC approach.

[01:00:23] Well, assuming that subway pushers are vastly, disproportionately, visibly homeless, I’m not riding the subway to get to work. We could that’s something that we absolutely could police our way out of. It won’t solve the mental illness problem, but it’ll solve the subway. Pushing problem with that person isn’t allowed to remain in the subway by choice. That’s a pretty easy solution. That’s a policy decision. Where they go, I don’t know. But at some point, we have to take the subway system into account to account exclusively about the care of the individual, even if the care of the individual should be the primary focus at some point. Yeah, just I don’t want you pushing people on the subway, but that’s these are choices that, you know, subway rules used to be enforced and that changed under de Blasio. Seems pretty simple to go back to the way it was for the previous 15 years.

[01:01:18] And also, you need to be talking about like protecting the homeless population. So what are the least study problems? And homelessness policy is homeless on homeless crime. I mean, you mentioned earlier the Chinatown murders, also the incident down to near the South Street Seaport and the incident of the ATRA with the first called the Atrium River, a number of his victims or other homeless people very frequently on these violent crimes. Koch, the victim was a homeless person. You know, the situation, anything that occurs inside a shelter has to have been perpetuated by a homeless person because nobody else can get into a shelter other than homeless people.

[01:01:57] So, you know you know, George Kelling wrote when he when subway rules were written and then verified the constitutional constitutionality was upheld by the courts. George Kelling wrote that the key moment was it was gaining the moral high ground.

[01:02:20] And he said that happened when some people were being ejected from the subway for violating rules and put in the vans. That was taking them to services and shelters. And there were advocates literally trying to drag people out of vans so they could remain in the subway system.

[01:02:38] And he believed till the day he died. And I concur with this belief that it is not humane. The subway is not a good shelter system because of danger, because of lack of facilities.

[01:02:54] And so once you get the idea that somehow, yes, you have to gain the moral high ground. This isn’t just about being mean to make other people’s lives less unpleasant.

[01:03:05] It’s also it’s dangerous. Most crime is not.

[01:03:11] Yeah, I assume that actually most of the crime down there is almost on the victims are homeless people as well as easy targets. That seems like it shouldn’t matter more than I think it does.

[01:03:25] But I don’t know who is there, are there is there a rational voice on these issues? I mean, part of a problem with any of these niche problems? Because granted, still the number of people being pushed in front of subway trains is not large, but most people simply have other things to worry about. They’re not focusing on these things. I’m sort of the loudest voice in the room problem. Who?

[01:03:51] Well, yeah. The Transit Workers Union have been pretty vocal about it. These are these are front line heroes who are still going to work in the dark days of March and April and having to steward these, you know, mobile homeless shelters.

[01:04:09] It’s amazing to me that progressive politicians in New York City ignore the minority majority transit union.

[01:04:17] Blue collar minority workers were saying, we need more policing down here.

[01:04:22] And yeah, it’s the politicians talk about decolonization and defunding. That’s that’s an odd disconnect to me. But.

[01:04:31] I mean, Larry is very good now, just saying politically, the union apparently doesn’t have enough clout because I don’t think they’re winning this battle, but it is a voice that should be heard more.

[01:04:43] Yeah, and I think that with this situation, with the reopening frames, this challenge in a much different way, because traditionally you rely you rely on crowds to regulate disorder in this traditional Jane Jacobs way and, you know, maybe tour. We might see tourists coming back to some degree in the summer. But the commuters who are a huge portion of the crowds, I think there’s a lot more uncertainty about if or when they’re coming back. And, you know, relying on crowds is a non governmental, non public safety response disorder. But then the ball gets put in the lap of the government and public safety agencies of that. But that solution remains unavailing for the time being.

[01:05:39] And the number I got one to do, you know, what is the estimate for the number of people living in the subways? We’re talking hundreds, if not thousands.

[01:05:48] Well, when New York City does its street count. But if I remember correctly, at least half of the unsheltered population is found in the subways and the train station at Grand Central, and that’s is probably a pretty severe undercount of the actual street homeless.

[01:06:09] But anyway, the data we have.

[01:06:12] So, yeah, and, you know, there are more people like one statistic I can give you. There are more people living in the subway system than in than in Queens. This the street count tends to turn up. A very small number of people living above ground in Queens and Queens is enormous. And in Queens is like the size of Houston and but by the terms. So there’s a way in which the subway system like sucks in many of the unsheltered, much of the unsheltered population away from the other boroughs. I mean, it’s Manhattan and the subway system that you find the street population really concentrated in city.

[01:06:52] You know, we despite my always, Miria, we’ve gone over an hour, I think by now, and I try to limit it there, but we could go on. I want to thank you. And we’ve really talked about to diverge. I worry about the fact that we sort of blended homelessness and mentally ill here when it is always important to put a legitimate caveat that, you know, what we’re not saying is that everyone out there is some violent homicidal maniac by any means.

[01:07:23] But these problems do overlap and they’re often not talked about honestly.

[01:07:29] So I appreciate your essay to the violence reduction project and what you’ve had to say here.

[01:07:38] Any last minute thoughts on your mind that, you know, when we talk about the broader problems with violence in New York City, you know, you’re talking about like Gates, right? Surely the homeless population contributes less to the murder rate than gangs. Throughout the 2010s, we saw soaring single adult homelessness, but a moderate to declining serious crime rate. So there is a way in which these are different problems. But, you know, the disorder is if for no other reason than just the need to address the disorder itself, we are going to need to somehow come to terms with the role of the criminal justice system, including the police, and addressing the homelessness challenge in all its complexity.

[01:08:27] Thanks. That is Stephen with a PH and Eide is spelling E I D E, and this podcast is up and qualitypolicing.com.

[01:08:40] And you can also get a link there and click through to the Violence Reduction Project and read his essay on these issues. Stephen is a senior fellow at the Manhattan Institute for Policy Research and he looks at state and local finance and social policy questions, particularly homelessness and mental illness. And I am Peter Moskos and this has been quality policing. Thanks for listening.