The Politics Of Involuntary Commitment
AILSA CHANG, HOST:
For New York City resident Sarah Trigg, one of the major draws of the city has been the subway.
SARAH TRIGG: When I consider other cities to live in, it's something that I hold close to my chest 'cause it's amazing to be able to just jump on a subway wherever you are.
CHANG: But one night a few months ago, she had an unsettling encounter on her way to the M train. The station was deserted except for...
TRIGG: A pretty heavyset man just throwing himself against the window. No one was there helping him. I couldn't enter the station. I had to change my plans.
CHANG: Trigg told NPR's Jasmine Garsd that she's seen a noticeable shift on the subways.
TRIGG: You know, I've been in New York since '96, and it's definitely gotten worse.
CHANG: New York City has been struggling with homelessness for decades, but recent numbers are the worst in generations. That's according to a group called the Coalition for the Homeless, which tries to estimate how many people in the city spend their nights in shelters, in tents and on sidewalks. The group's policy director, Jacquelyn Simone, says it's gotten worse with the pandemic.
JACQUELYN SIMONE: People who were very tenuously housed, some of them went into the shelter system and some of them ended up on the street.
CHANG: And as services moved online...
SIMONE: People who were trying to maintain engagement with mental health or substance use providers had an increasingly difficult time doing so.
CHANG: The crisis has become especially visible on the subways after several incidents involving unhoused people and the subway system. That included one passenger who was killed after being pushed in front of a train by a homeless man with a mental health condition. At the end of last year, New York City Mayor Eric Adams laid out a plan that relied on involuntary hospitalization to face this crisis.
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ERIC ADAMS: If severe mental illness is causing someone to be unsheltered and a danger to themselves, we have a moral obligation to help them get the treatment and care they need.
CHANG: That announcement sparked an outcry among activists who saw it as an attack on poor New Yorkers rather than a real attempt to offer help. Others were concerned the city lacked the resources required to expand involuntary hospitalizations. Here's former NYPD Commissioner Bill Bratton.
BILL BRATTON: Not much has changed other than there's fewer places to put these people for long-term care. The resources aren't there. It's a - it's quite a conundrum.
CHANG: But the big problem that many critics have with this proposal from Mayor Adams is concerned that it could end up targeting people who aren't unstable but instead are just poor and living on the streets.
SIMONE: There is a real risk that people will be swept up who don't actually meet the standard for involuntary treatment. They could really risk having police and other people without adequate training just removing people from the street involuntarily because of the fact that they're homeless.
CHANG: In an interview with NPR, Mayor Eric Adams responded to that concern.
ADAMS: We are not saying everyone with a mental health illness is all of a sudden going to be swept up and put inside of some institution somewhere. No, we're saying the small number that fit into a specific category of not being able to take care of their basic needs and are a danger to themselves or others - that is the group we're talking about.
CHANG: Adams' plan actually makes sense to Jerome Granville (ph), who's 36 and says he's been on the streets for years.
JEROME GRANVILLE: Sometimes some people don't realize they're going through something, and they might need a little bit of help. So he's doing something right.
CHANG: But Granville says what he needs most is a place to live.
GRANVILLE: Only thing I need is housing. Housing will help me because when I get a job, I'll have somewhere to go home and take a shower and rest.
CHANG: And that is exactly what advocates have been saying for years - that the problem of homelessness cannot be tackled without creating more subsidized and affordable housing. Mayor Adams said he agrees, but he also said there is a crisis now.
ADAMS: What are we going to do now? No one is willing to stand up and say, while we're building that housing, what are we going to do with that person that has severe mental health illness and cannot take care of their basic needs?
CHANG: CONSIDER THIS - as mental health, the drug epidemic and homelessness increasingly become political problems, more Democratic-led cities and states are reconsidering how they approach the challenge of when to treat people who resist treatment or who don't know they even need treatment. After the break, we'll hear how politicians in two Western states, Oregon and California, are discussing expanding involuntary commitment.
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CHANG: From NPR, I'm Ailsa Chang. It's Wednesday, March 29.
It's CONSIDER THIS FROM NPR. Half of the unsheltered population in the U.S. lives in California, a state that has had a strong streak of medical autonomy over time. Even though only a quarter or a third of the state's homeless population is estimated to have a serious mental illness, that's where a large number of new policy proposals surrounding involuntary commitment are being directed. In March 2022, California Governor Gavin Newsom unveiled a new plan to provide community-based care to people struggling with severe mental health and substance use disorders.
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GAVIN NEWSOM: This is about accountability, but it is about compassion. And it's about recognizing the human condition.
CHANG: Meanwhile, in Portland, Ore., Ted Wheeler, the city's Democratic mayor, has indicated support for loosening the criteria for involuntary commitment to deal with a homelessness crisis in his city that he called, quote, "nothing short of a humanitarian catastrophe." At a forum for Portland business owners last November, he said his support was based on his own moral and ethical judgment.
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TED WHEELER: When I see people walking through the elements without appropriate attire, often naked, they're freezing to death. They are exposed to the elements. They - I don't even know if they know where they are, who they are. They need help, and they need compassion.
CHANG: But the momentum for expanding policies like these looks different in Oregon versus California. And to better understand how the conversation about involuntary commitment is playing out in those two states, I spoke with April Dembosky of member station KQED in San Francisco and Amelia Templeton with Oregon Public Broadcasting. In California, April explained, Governor Newsom and state legislators are trying to roll out something called CARE Courts.
APRIL DEMBOSKY, BYLINE: This is where a family member or a doctor can refer someone who has a psychotic illness to court. And a judge will draw up a care plan that the person is strongly encouraged to accept. Another recent proposal is to expand who qualifies for involuntary commitment. One doctor told me about a patient who's homeless, who has both diabetes and schizophrenia, and he keeps cycling in and out of the emergency room because he's not taking his diabetes medication, and that's because he's not taking his antipsychotic medication. So right now, doctors' hands are tied with a patient like this because being unable to take care of your own medical needs is not a reason that doctors can intervene under the current law. And that is something that they want to change.
CHANG: And what's been the reaction so far to these proposals?
DEMBOSKY: Both of them have been hugely controversial. I call it a war of compassion, actually, because both sides want to do the right thing. On one side, you've got disability rights groups saying forcing people into treatment against their will is a violation of their civil rights. You know, locking people up just for being sick, that's not compassionate. But on the other side, you've got families and doctors who say, well, what about people's right to medical care? You know, leaving someone lying on the street unable to care for themselves, that's not compassionate either.
DEMBOSKY: So here's how Teresa Pasquini puts it. Her son has schizophrenia, and she says the problem is doctors can only step in after a tragedy has occurred.
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TERESA PASQUINI: We will no longer settle for the status quo that has forced too many of our loved ones to die with their rights on.
CHANG: I see the conflict over what values ultimately should predominate when you're talking about severely mentally ill people. And I'm wondering when you're looking at a value like compassion, in Oregon, Amelia, how does that value play out in this debate?
AMELIA TEMPLETON, BYLINE: Well, there's absolutely a parallel debate here over what the compassionate approach is and whether we've drawn the line in the right place for civil commitment. But the politics are a bit different. Portland's mayor, who is a moderate Democrat, has talked about loosening the criteria for civil commitment in interviews with national media. And also it's a talking point he brings up in meetings with downtown businesses that are really upset about homelessness. But in Oregon, it's really just talk. Democrats in the state legislature have not embraced the idea. Republicans have introduced several bills that would expand who could be forced into treatment, but they're very much in the minority. And the bills are widely considered dead on arrival.
CHANG: And why is that? Why is changing civil commitment such a nonstarter in Oregon where, like, in California, they're honestly considering changing it?
TEMPLETON: I think a few things are still different here. First, the power to force a civil commitment in Oregon is very narrow but maybe not quite as narrow as in California. So to take one of April's examples, in Oregon, a person who is not taking diabetes medication due to psychosis, that person could be successfully civilly committed. The legislature made a small change in 2015 that makes those cases a little easier to pursue. But there's real resistance to going further. And the biggest issue by far is treatment capacity for mental illness and substance use disorders. There's just limited political interest in forcing more people into treatment when the system can barely handle the patients it has right now.
CHANG: Wait, wait. What do you mean by that?
TEMPLETON: Well, Oregon is actually being sued by three of the largest hospital systems in the state over its failure to find placements for civilly committed patients because otherwise, what happens is these patients are getting stuck in hospitals, sometimes for months. The state has two dedicated psychiatric hospitals with about 600 beds total. And over the last decade, more of those beds have been needed for people who are in county jails who are too mentally ill to understand the charges against them. So the result is that most civilly committed patients are denied a bed at the state hospital. And then there's no community beds either, like sending someone to a nursing home or an adult foster home or a residential treatment facility. Those beds were in really short supply already. And then in Oregon, the pandemic just gutted those places. So in Portland, for example, one of the nursing homes that suffered one of the very first devastating COVID outbreaks was a place the state had been relying on to place psychiatric patients. Twenty-eight people died, and it was shut down permanently.
CHANG: Well, April, is this capacity problem, this question of where do you even send people for treatment, is that a real concern in California, too?
DEMBOSKY: It's a huge concern and a huge problem. Opponents of these measures are pointing out we already don't have enough treatment beds or mental health clinicians for the folks who are voluntarily asking for treatment. And then proponents of the reforms are saying, well, you know, passing these laws will put a spotlight on this, and it will force a fix. So that remains to be seen. But the bigger capacity question here is really one of housing. Advocates will say homelessness is a problem caused by a lack of affordable housing, not mental illness. One doctor told me it's like musical chairs. If you have nine chairs and 10 kids, the kid with a broken leg is going to be the one left without a chair. Well, if you don't have enough housing, it's folks with mental illness who are most likely to have trouble competing in a market of scarcity. UCSF doctor Margot Kushel told me the solution is more housing, not involuntary treatment.
MARGOT KUSHEL: If you try to fix the problem of homelessness by tinkering with the health care system, we're not going to get anywhere.
DEMBOSKY: For the record, the same California lawmakers who are backing these new mental health reforms are also backing ways to increase the housing supply.
TEMPLETON: I mean, we're talking about two states where the rents have risen so much faster than people's incomes. And that is a gap that's worse for people who are living on disability income, which can include people with mental illnesses. Here in Oregon, the new governor, Tina Kotek, says housing is her top priority. And Oregon is trying something really novel. It's the first state in the nation that will use Medicaid money to pay for things like rental assistance. So starting next year, if you're homeless and Medicaid is paying for your substance use treatment or other mental health issue, it might also pay for your housing.
CHANG: That was Amelia Templeton with Oregon Public Broadcasting and April Dembosky with KQED in San Francisco. Both are part of NPR's health reporting partnership with Kaiser Health News. This episode also featured reporting from NPR's Jasmine Garsd.
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CHANG: It's CONSIDER THIS FROM NPR. I'm Ailsa Chang.
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