By Stephen Eide, senior fellow at the Manhattan Institute
To improve public safety, governments across the nation need to provide more supervision for mentally ill people. That can happen either in a hospital or community-based setting, and under involuntary or voluntary conditions.
Supervision is a necessary condition of effective treatment. Somewhere around 40 and 50 percent of seriously mentally ill individuals receive no treatment for their condition. As a result, they are often involved in subway pushings and other random assaults on strangers and comprise 15% to 20% percent of the incarcerated population, despite comprising only around 5% of the adult population. A 2015 report by New York City’s Independent Budget Office suggested that, among the local jail population, inmates with a mental disorder tend to commit more serious crimes than inmates without a mental disorder.
Many mental health programs do not target those most at risk of “falling through cracks.”
In short, if mentally ill people committed crime at a rate roughly equivalent to their share of the population, there’d be less crime overall. To get there, we’ll need more effective treatment, which will require more effective modes of supervision.
“Supervision” is a much less buzzy term, at present, than “diversion.” Mental health diversion policies “divert” the mentally ill from the criminal justice system. The most prominent example would be sending social workers to respond to 911 calls. Diversion proponents argue that contact with the criminal justice system is nearly always harmful for someone with schizophrenia. About 200-250 mentally ill individuals are shot to death annually by police, and the experience of incarceration is generally assumed to exacerbate mental illness. But diversion is a negative goal. It always raises the question, “diversion to what?”
Throughout the latter decades of the 20th century, deinstitutionalization “diverted” thousands of mentally ill individuals from mental institutions to jails, prisons, homeless shelters, and the streets. It was one of the sadder chapters in the history of American social policymaking.
The pendulum has swung too far on psychiatric hospitalization. Public beds are down over 90% percent from their mid 20th century peak, they’re recently been falling still more, in some jurisdictions, and COVID has prompted further cutbacks. But supervision is not just about hospitals. Community mental health services can stabilize people before and after they enter a state of crisis so acute as to necessitate hospitalization. Examples include Fountain House, a New York-based “clubhouse” program, probation-style programs such as mental health courts, and outpatient civil commitment, such as New York’s Kendra’s Law program.
The sine qua non of enhanced supervision in the mental health context is the targeting of the seriously mentally ill, meaning especially people with schizophrenia and bipolar disorder. Many mental health programs do not target those most at risk of “falling through cracks.” That phrase means going off one’s anti-psychotic medication, “self-medicating” with street drugs that make one’s disorders worse, losing contact with loved ones and service providers, and getting arrested.
It may be good public policy to assist low-income women dealing with post-partum depression and anxious children attending underperforming schools. But politicians mislead when they suggest that addressing those problems will reduce the rate of untreated schizophrenia. Government needs to do a better job of parsing which community programs do deal with those at risk of being involved in a subway pushing, determining which providers are more effective at maintaining contact with such individuals, and invest more in such programs.
“Supervision” carries paternalistic overtones disliked by the disability rights community. A major reason why governments don’t target programs towards the seriously mentally ill is excessive sensitivity over “stigma.” Social discrimination against the mentally ill allegedly creates major barriers to treatment. But the real barrier to building a better mental health system is the assumption that extraordinary illnesses can be treated through ordinary means.
The path to a lower rate of untreated serious mental illness does not lie through increased expansion of personal freedom. Emphasizing the connection between violence and mental health reform is not just fear-mongering. In late 2016, President Obama signed into law the most substantial federal mental reforms in years as part of the “21st Century Cures Act.” Those reforms originated out of a Congressional investigation into the mental health system that was touched off by the 2012 mass shooting in Newtown, Connecticut.
If one squints, the argument that mental health reform will reduce violence resembles “defund the police” advocates’ claims that the best way to address crime is through “upstream” investments in social services. But not as much, if the core concept of mental health reform is “supervision,” a term more closely associated with criminal justice than the social services. Many progressive politicians are now focused on trying to free the social services from any involvement with the criminal justice system and its intellectual influence. A bill now under consideration by the New York City Council would prohibit homeless outreach work by police officers.
But here we see the value in focusing on the case of the mentally ill for the broader debate over defunding. The social services, when dealing with the hardest cases, have never found a way to dispense wholly with public safety-type functions. We need security guards in psychiatric hospitals and homeless shelters, and we sometimes need to employ treatment over objection and involuntary civil commitment. We need to use coercion, but better supervision will prevent the need from unnecessary and excessive coercion. As well, it would lead to safer cities.
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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.
