How to meet the need for mental health services in NYC?

The tragic killing of Jordan Neely has reignited discussions on how best to address the mental health needs of New Yorkers. During the 8th Annual Lillian Wald Symposium, a panel of diverse experts with frontline experience in the mental health field, discussed the dramatic range of challenges to providing appropriate mental health care to those who need it. Their discussions also broached solutions that crossed the health system, housing, and medical research fields.

Henry Street Settlement President & CEO David Garza, in kicking off the symposium held April 12, said that his team members are witnessing the impact and devastation of mental illness on the populations they serve throughout the agency’s programming, from direct counseling to workforce, aging, afterschool and arts services.

Lillian Wald, a nurse and the founder of Henry Street Settlement “felt it was a responsibility to bring people to the table to talk about critically important issues and mental health,” Garza said. Social issues related to mental illness are not new but have been exacerbated by the coronavirus pandemic, which left people with feelings of loss, isolation, disruption and unpredictability. For a significant part of its history, Henry Street has offered mental health care. Its Mental Hygiene Clinic, now called the Community Consultation Center, opened in 1946, and was one of the first community-based mental health clinics in the country, located in public housing at 40 Montgomery Street.

Moderator Andy Newman, social services reporter for The New York Times, introduced five panelists participating in the symposium: 

• George Aumoithe, assistant professor in the Department of History and the Department of African and African American Studies at Harvard University
• Jose Cotto, senior vice president for residential treatment at the Institute for Community Living
• Omar Fattal, system chief for behavioral health and co-deputy chief medical officer at NYC Health + Hospitals
• Jo-Ann Abrams, psychiatric nurse practitioner at Henry Street's CONNECT program
• Arvind Sooknanan, board member and community advocate at Fountain House

Defining the Mental Health Crisis

Newman asked panelists to define the mental health crisis. Abrams, who provides street-level care both through Henry Street and the Bronx Intensive Mobile Treatment team, responded, “It’s in chaos. The structure and foundation that I’m used to seeing is totally gone.”

With regard to people on the schizophrenic spectrum who require long-term treatment, Abrams said she has had difficulty getting access to care. Patients are hard to get admitted into the emergency room, are frequently discharged; their length of stay has been cut from the usual four weeks to as little as three days and discharges are abrupt. Moreover, patients are being seen by professionals who are not familiar with necessary medications and do not often receive follow-up outpatient services, she said. Fattal countered that city hospitals do extensive evaluations and keep patients for as long as needed.

Abrams provides street-level care with a team of mental health professionals, including a “peer” who helps calm clients who have a lack of trust in providers. Schizophrenic patients are often criminalized, she said, yet they are not criminals; they are people who have been poorly treated by the mental health system. In addition, use of cannabis, K2, and heroin added to delusions and hallucinations, making it difficult to diagnose.

Staffing shortages are a major factor

“What makes this a crisis is the mismatch between the need and the workforce,” Fattal said. The conditions of the pandemic led to medical professionals increasingly choosing remote work over work in the field, and people who were able to, retired. The pandemic has shown a simultaneous increase, Fattal said, in both prevalence of mental health-related conditions and awareness. This awareness has led to more people coming forward seeking help with their mental struggles, but the staffing does not meet the demand. He echoed Abrams, saying that drug use has proved to be a major factor affecting schizoaffective patients.  

“There was an 80% increase in overdose deaths between 2019 and 2021,” Newman said, when asking the panelists about data that shows the crisis worsening. 

Fattal explained, “children have been affected the most.” An increase in suicidality, anxiety, self-injury and depression among youth has severely changed communities, and the youth component plays a major part in the increase in the need for mental health support. 

Sooknanan is not only an advocate and board member of Fountain House but also a participant in the Bronx Club House who lives with mental illness. Diagnosed with schizoaffective disorder at 16, Sooknanan recalled the difficulty of finding a psychiatrist or therapist who took his insurance and met his needs as well as the class and racial disparities he faced as the child of low-income immigrants. Between 15 and 19 years old, Sooknanan was hospitalized over 20 times. 

“When I was in those facilities, I saw one or two types of patients. One type was usually wealthy white kids, and the other were kids that looked like me,” Sooknanan said. The latter often received no outpatient plan, no continual care or support, and had nowhere to go. To receive adequate support, Sooknanan had to travel upwards of an hour and a half from the Bronx, a hurdle that is common for people of his community.

Henry Street Settlement and Fountain House provide the type of community-based care that panelists consistently acknowledged is essential, but the need is much greater than available resources. Sooknanan said that 90% of Fountain House members are of color and that this factor played a pivotal role in his finding comfort there.

 “Every other mental health facility I went to, I felt as if I was speaking to a prosecutor,” Sooknanan said.

“I don’t think the crisis is larger than it was before. It’s always been there. For decades this has been a problem. Across the country, there are 14 million people living with a serious mental illness diagnosis. The access to care has only gotten worse because of the pandemic,” he added.

New York state has the most psychiatrists in the nation, said Sooknanan, yet many people do not have access to care for myriad reasons: insurance, overwork and burnout of staff members, and more. Sooknanan said there are two separate tracks for people in the health care system: those with mental illnesses and those with serious mental illnesses. Both sides have their own narratives and stigmas attached to them, which can make the work difficult. 

Sooknanan relayed his experience of police intervention during a mental health episode he had in his teen years. Although he was in his home, unaggressive and barely clothed, the police tackled him and put him into handcuffs.

“Does it make sense when someone is really struggling … to have a man with a gun show up? I would get more scared, wouldn’t you? I can’t emphasize the importance of trust and community,” Sooknanan said.

Mayor Eric Adams’s push to use police officers and clinicians to remove mentally ill individuals who pose a risk to themselves or others from the street met with heavy blowback and criticism from advocates and community members. Fattal said, however, that, with more than 50,000 patients arriving in public hospitals for behavioral services a year, he has not seen an increase in their numbers. These hospitals have been increasingly connecting patients to a state Office of Mental Health–run Transition to Housing Unit, where people can go after a time in a psychiatric inpatient unit – and to the Extended Care Unit at Bellevue Hospital and a similar unit that just opened in Kings County Hospital. Patients can stay up to 90 days within these units.

Historical context for today’s crisis

Offering some historical context, Aumoithe noted that around 1855, the idea first emerged of U.S. hospitals providing long-term mental health services for people on the schizophrenic spectrum. 

“A lot of the things that we are missing today existed between 1855 and 1940,” he said, such as a commitment among institutions to care for the mentally ill, a donor base in the community and people who saw the hospitals as places where they could claim care for their loved ones. There was racism and abuse in these facilities, but there was also compassion and care across a long time frame. A shift began in the 1940s to a greater emphasis on community care – a time when there were only eight Black psychiatrists in the U.S., Aumoithe said.

Practitioners like Lillian Wald were trailblazers for community-based nursing, which brought health professionals into homes and on the street, while building longstanding social relationships with their patient families.  

By the 1960s and the Civil Rights Movement, Aumoithe said, state hospitals were closed due to the perception that hospitals for the mentally ill were places where people were being abused, despite that they were the only places where people could get long-term care. 

In 1963, the Kennedy Administration passed the Community Health Act, promoting a version of community care that “was not necessarily in line with Lillian Wald’s vision but was more in line with a vision of cost cutting and penny pinching,” Aumoithe said. That led to people being cast out of hospitals on a broad scale. This is how the mentally ill went on to being viewed as “street people” or criminals, Aumoithe added. 

Today’s tension between the rehabilitation versus criminalization of people with mental illness dates back to the 1970s, Aumoithe explained, as the nation’s reinvestment in hospitals converged with the War on Drugs. “This is the very moment that the population not connected to long-term care is being seen as the source of racial violence, a problem population and incarcerated,” Aumoithe said. Needle and syringe exchanges of the ’80s and ’90s had to go through a district attorney’s office before they could open. 

Cotto and Aumoithe both addressed the role of racism in mental health care. Cotto noted that the history of racism in health care – from the Tuskegee study of Black men to today’s unequal access to COVID-19 education and vaccines to Black maternal mortality – also applies to mental health care. 

What the system is missing

Panelists also shared ideas on what the mental health care system in New York City is lacking. Cotto described the extensive hurdles that those with mental health challenges need to overcome to find supportive housing. Abrams noted that many nurses are not being trained to handle patients on the schizophrenic spectrum – and some are seeking easier jobs, which decreases the quality of mental health services. Adequate education of nurses and all mental health professionals would cover the gap in knowledge that is needed to properly take care of patients, she said.

1. Abrams added that there is not enough research being done on schizophrenia. “We are only guessing,” she said, and do not know what schizophrenia is caused by. “Without knowing the source, it is difficult to put preventative measures in place for these patients.”

“We need more staffing on all fronts, more housing and less shelters, integrated care, more funding, and more nursing,” Cotto said. “There is a need for behavioral health to be treated with the same intensity as physical health.”

An abundance of solutions

Panelists shared their thoughts on actionable solutions that can improve the mental health care system today, beginning with fighting stigma.

“This reminds me of the HIV crisis,” Abrams said. In the last few years, the mental health crisis has received a lot of media attention, but stigmas surrounding mental health have not changed. Having a mental illness “doesn’t define you. You are not your illness,” Abrams said. 

Cotto noted that far more resources need to be provided to both patients and health care professionals to solve this crisis. There is a need for more community hubs, leveraging misused housing to create spaces for healing and making the profession more attractive to broaden the applicant pool for new staff.

Ultimately, according to Cotto, there needs to be the same emphasis on mental health as placed on physical health. More psychiatric beds are needed, including those that were taken offline during the pandemic, as well as more nursing and more supportive housing beds. Still, he said a number of creative solutions are under way. Manhattan Psychiatric Center beds have been converted to a THU, the 90-day unit where people can continue to recover after an inpatient stay. 

Fattal said he believed that the current discussion of the mental health crisis at state and local levels is finally bringing attention to a long-neglected issue, and that things may be getting better. He is seeing an opportunity for the mental health system to expand, with hospitals listening to psychiatrists and mental health practitioners whose issues sometimes evade the spotlight. In the recent past, he said, the governor and mayor have prioritized this issue, and funding is following. NYC Health + Hospitals has been working to expand outpatient services, reopen beds, expand substance abuse treatment, and expand street homeless outreach van programs. 

Sooknanan noted the need for more “community-based care like Fountain House and Henry Street.” Community-based care can be an effective solution, he said, because it reduces expenses for patients while giving access to education, employment, health and wellness, and other social services.

“We should focus on crisis prevention, and that includes taking down stigma,” Sooknanan said, to conclude the discussion.

The symposium was organized by Henry Street’s public historian Katie Vogel. To view the panel discussion in full, click here.