There’s no more striking visual symbol of our city’s challenges than the homeless we see so often these days, especially on the subways. Some mornings you can find a troubled person sprawled out asleep in car after car — or menacing riders and adding undeniable tension to already harried commutes.
But these are not villains. Locking them up is not the answer. Many suffer from untreated serious mental illnesses, and they need help. This is a health crisis. And we must have compassion for them, as we have compassion for subway riders who deserve an efficient commute free of worries for their safety.
Challenges like mental illness and homelessness — so often intertwined within a gnarly nexus of emergency rooms, prisons and shelters — require innovative strategies and collaborative approaches. We can learn from leaders in the clinical treatment, law enforcement, faith community, supportive housing and community health systems. Equally as important is to engage advocates, individuals and family members who have lived experience with serious mental illness and disabilities.
There is no “one size fits all” solution.
As the highest-ranking psychiatrist in the U.S. Army, I saw mental illness in all its debilitating forms. As New York City’s first commissioner for the Department of Veteran Services, I led a team that effectively ended chronic veteran homelessness in 2015; decreased veteran homelessness through 2019 by 85%; and, with our city agency and community partners, placed thousands of veterans into permanent housing. In the nation as a whole, the success rate was 43% during the same time period.
The innovations accounting for this outsize impact could, should and must be fully applied across the city’s entire homeless population.
One of the most pioneering approaches was developed more than 70 years ago right here. Called Fountain House, it’s a clubhouse model that was founded on the belief that people living with mental illness can actively participate in their own and each other’s recovery — loneliness kills.
I know this model, which is replicated in more than 30 countries, can be fully brought to scale here.
In New York we have another powerful tool: Kendra’s Law, which directs court-ordered treatment for up to a year, allowing those with serious mental illness to remain in the community. This program, highly successful at decreasing incarceration, homelessness and hospitalization, should be used more frequently.
Efforts are also underway and should be accelerated to create a path to civil involuntary commitment that prevents violence rather than requires it; to stand up residential programs diverting the mentally ill from prison to treatment; and to increase psychiatric bed capacity for stabilizing and treating those suffering from serious mental illness and addiction disorders.
At the same time, we must require the use of the Columbia Protocol, a simple set of questions that can help determine the level of suicidal risk and appropriate resources for individuals. Widely in use elsewhere, the protocol has yet to be fully implemented in NYC, where it was developed. With suicides increasing, it’s beyond time to do this.
However daunting, these are manageable challenges. Success is going to require firmness mixed with compassion. And it’s going to cost money.
How can this play out in practice?
Take Jake, a homeless young man I met sitting on a Manhattan sidewalk who acknowledges his need for help. He refuses, however, to enter the city shelter system because he experienced physical and sexual assault there.
But Jake could greatly benefit from joining a clubhouse, tackling his PTSD and opioid dependence issues and regaining his sense of purpose and pride through accessing peer social support, stable housing and transitional employment.
Let’s invest in his potential — and break the cycle of desperation and despair so evident with the many Jakes who are counting on us to hear their voices.
Sutton, a psychiatrist and retired brigadier general who was founding commissioner of the city’s Department of Veterans’ Services, is a Democrat running for mayor of New York.
