(Spencer Platt/Getty Images)

It’s Time to Mandate Treatment of the Dangerously Mentally Ill

What happens when we leave people with psychosis to their demons? Ask the families of Alison Russo-Elling, Nathaniel Rivers, and Michelle Go.

Last Friday in Queens, New York, Peter Zisopoulos, 34 years-old, described by his neighbors as an “odd, quiet loner,” suddenly set upon Lt. Alison Russo-Elling, 61, a veteran paramedic walking back to her station after lunch. He knocked her down then stabbed her to death in a frenzy. He is now being held at the Bellevue Hospital Prison Ward undergoing a psychiatric evaluation, awaiting clearance from doctors that he is stable enough to face arraignment on murder charges. Zisopoulos, who had been diagnosed with schizophrenia, was hospitalized in 2018 after allegedly making anti-Asian threats.

This attack is eerily like the one on that took place the afternoon of July 21, in the Bronx, when Nathaniel Rivers, 35, and his wife, the parents of a young son, were sitting in their car near their home, sharing a pizza, waiting for the rain to pass. 

Suddenly, 19-year-old Franklin Mesa came over to Rivers’ car window in an agitated state. Words were exchanged, briefly, before Mesa thrust a knife into Rivers’ chest. Rivers’ wife got out of the car, picked up a pry bar and clobbered Mesa. But it was too late: Mesa had mortally injured Rivers, who died a few minutes later.

Mesa, who has been charged with Rivers’ murder, is said by his family to have schizophrenia. He was well known in the neighborhood for “hostile, aggressive” encounters. Police said he was arrested last year for twice punching somebody in the face. Mesa reportedly once tried to prevent a young mother from getting on a bus.

And yet it appears that nobody made sure Mesa was taking his psychiatric medicine, which his sister said he had been on since he was 15. Had Mesa been properly medicated, Rivers almost certainly would still be alive today.

These horrifying deaths rekindle the national debate over how to prevent violence by the seriously mentally ill. Between 2015 and 2018, 911 calls reporting emotionally disturbed people have jumped by nearly 25 percent in New York City. The share of homeless people in New York with serious mental illness, usually defined as schizophrenia and bipolar disorder, has most recently been estimated at 17 percent.

Consider the case of Martial Simon, a 61 year-old mentally ill homeless man, who early this year confessed to pushing 40 year-old Michelle Go onto the subway tracks, where she was killed by an oncoming train. Go was a manager at Deloitte who was lauded for her extensive volunteer work with struggling New Yorkers, including the homeless. Simon has spent decades bouncing between jails and hospitals. Declared mentally unfit to stand trial for the murder of Go, Martial is now being held at a psychiatric facility

Years before, his sister saw something like this coming, and she pleaded with the authorities to prevent it. “I remember begging one of the hospitals, ‘Let him stay,’” she said, “because once he’s out, he didn’t want to take medication, and it was the medication that kept him going.”

The medical system was warned, by Simon himself, that exactly this was coming. As the New York Times reported: “A homeless advocate who saw Simon’s medical records reports that Simon even told a psychiatrist in 2017 that it was only a matter of time before he pushed a woman onto the subway tracks.”

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Though it is difficult to get an exact estimate, a large body of research makes clear that people like Zisopoulos, Mesa, and Simon are just three among hundreds of cases of people in New York alone—to say nothing of cities like Los Angeles, Seattle, San Francisco and others—in which mentally ill people off their medication have assaulted or killed people. And if you think the problem is getting worse, you are right. 

In 2021, felony assaults in New York’s subway were almost 25 percent  higher compared to 2019, despite a lower ridership because of the pandemic. The number of people pushed onto tracks rose from 9 in 2017 to 20 in 2019 to 30 in 2021. Psychiatrists and emergency department workers in San Francisco and Los Angeles tell me that they have seen a significant increase in homeless patients in psychotic states over the last few years.

How have we arrived at the point where we leave people with psychosis to their demons, and leave the public to take their chances? How have we allowed so many of our cities to have no decent plans or places for the burgeoning number of the violent mentally ill on the streets? 

There are two major forces at work. The first is that the U.S. never created a functioning mental health care system. The second is that powerful groups have effectively prevented dangerously mentally ill people from getting treatment. 

Starting in the late 19th century, the U.S. created large psychiatric hospitals, often in the countryside, known as asylums, for the mentally ill. Asylums were a major progressive achievement because they delivered, for many decades, significantly more humane, evidence-based care to people who, until then, had often been neglected, abused, or even killed. 

But by the middle of the 20th century, the reputation of psychiatric hospitals was in tatters—and deservedly so. Conditions in many of them were appalling, even barbaric. People who were not severely mentally ill were sometimes subjected to years of involuntary hospitalization. 

Many reformers just wanted better funding and oversight, but other reformers were more radical, and proposed shutting the hospitals down entirely and replacing them with community-based clinics. Some reformers claimed that serious mental illnesses were the result of poverty and inequality, not biology, and argued that they could be cured through radical social change. 

The reformers largely won. State hospitals were shut down in droves before sufficient community centers could be built to treat the suffering. Over the next two decades, as state mental hospitals emptied out, many released patients ended up on the street, or incarcerated. Those community clinics that did start operating tended to treat “the worried well”—those suffering from comparatively low-level anxiety and depression, rather than psychosis. 

Decades later, governments were still cutting funding for the treatment of the mentally ill. New York State in 2010 reduced Medicaid reimbursement for inpatient stays of the mentally ill in hospitals beyond 12 days. As a result, New York hospitals released the mentally ill earlier than they should have. From 2012 to 2019, the number of mentally ill adults in inpatient psychiatric care in hospitals and mental institutions in New York City declined from 4,100 to just 3,000. Meanwhile, the number of seriously mentally ill homeless people rose from 11,500 to 13,200.

The story is similar in California. Between 2012 and 2019, more than one-third of the group homes in San Francisco that served mentally ill and disabled people under the age of sixty closed their doors. Why? The measly Medi-Cal and Medicare reimbursement of $1,058 per person per month, and rising estate prices, made it more valuable for the private owners of group homes to sell than to keep operating them. 

At the national level, the same dynamic was in play. The U.S. as a whole lost 15,000 board and care beds for the mentally ill and disabled between 2010 and 2016. Today, approximately 121,000 mentally ill people are conservatively estimated to be living on America’s streets. 

And even when money is available, it doesn’t result in the kind of supervised treatment the severely mentally ill need. In 2004, California voters passed historic legislation, the Mental Health Services Act (Proposition 63), which generates $3 billion per year, and was promoted to voters as a way to address untreated mental illness among the homeless. 

Flowers for Christina Yuna Lee in front of the Chinatown building where she lived and was murdered by a homeless man. (Andrew Lichtenstein/Corbis via Getty Images)

Have you been to Los Angeles or San Francisco lately? Despite the Prop 63 windfall, California has a 30 percent higher rate of mentally ill people in jails, and a 91 percent higher rate of mentally ill people on the streets or in homeless shelters, than the nation. 

This is due largely to the influence of the American Civil Liberties Union, the New York Civil Liberties Union, and lesser-known disability rights advocacy organizations and coalitions, which have sought to de-fund psychiatry, de-police cities, and de-stigmatize untreated mental illness. 

From the 1960s to the 1980s, the ACLU and its allies successfully fought for laws to severely restrict the ability of family members and police to require the mentally ill get treatment. An often unacknowledged irony is that the homeless mentally ill themselves are at grave risk on the streets where they are frequently victims of violence and crime.

Lack of legal tools to impose life-saving involuntary care has made some parents of the seriously mentally ill desperate enough to support the arrest of their children. One mother of a schizophrenic son from the Sacramento area pressed charges in 2020 against her son after he grabbed her car keys and purse and drove off with her car, and explained this terrible choice, “It’s the only way. If they’re not willing to go for help, there’s nothing you can do.” 

There are humane ways to mandate treatment of dangerously mentally ill people without hospitalizing them. Kendra’s Law, passed by New York legislators in 1999, is named after a writer who was killed after being pushed onto the subway tracks by a mentally ill man who had stopped taking his medications. 

This law allows courts to order medical treatment of the mentally ill without requiring hospitalization. Patients get injectable antipsychotic medicines that last a full month. These are tailor-made for delusional schizophrenics who are convinced they are not sick and don’t need their meds. Conservatives and liberals agree Kendra’s Law prevents violence. It allows action to be taken before a mentally ill person hurts somebody.

Yet there was an 8 percent decline in the number of individuals treated under Kendra’s Law between 2017 and 2021. Why? Once again, because the New York Civil Liberties Union, the New York affiliate of the ACLU, and other progressive “disability rights” groups have sought to weaken the law, claiming it is authoritarian and racist, while also seeking to prevent police officers from responding to 911 calls relating to the mentally ill. 

Why do the ACLU and other progressive organizations do this? An attorney for the ACLU told me that her organization believes the mentally ill are too impaired to be held accountable for breaking the law—but not impaired enough to justify the kind of legal guardianship we provide to people suffering from mental disabilities such as dementia. 

I asked the ACLU’s lead attorney on the issue, Susan Mizner, why the ACLU opposed conservatorship for people suffering psychosis but not for people with dementia. “The biggest difference,” she said, “is that dementia tends to be more constant and deteriorating whereas psychiatric disabilities are more episodic and responsive to treatment.” 

While Mizner is right that psychiatric illnesses are amenable to treatment, the problem is the minority of seriously mentally ill people who refuse treatment, and groups like the ACLU who empower them.

The underlying problem is that the ACLU and other progressive libertarians view the mentally ill as victims of society deserving of special rights, including the right to avoid the consequences of their behavior. They hold the view that, “Quite simply, there is no place for coercion,” in the words of a recent disability rights coalition’s letter to the governor of New York. The deaths of people like Alison Russo-Elling, Nathaniel Rivers, and Michelle Go are the direct result of such dogmatism.

Advocates for public safety and enhanced treatment for the mentally ill argue that New York City should focus its limited resources on those with major mental illness, rather than what it does now, which is to spread its resources too thin. In 2018, just 3,158 patients were under active Kendra’s Law court orders in New York state, even though around 8,000 could have qualified, according to advocacy group Mental Illness Policy Org.

Such focus would require a greater centralization of care and a significant expansion of hospital beds. What’s needed is a single agency, let’s call it “New York Psych,” to address this growing crisis. While we should never stigmatize people with mental illness, we should stigmatize untreated mental illness. We went too far in de-institutionalizing, de-policing, and de-stigmatizing. We need psychiatric institutions, police, and the right to public safety. Our officials need to concentrate on the serious illnesses that lead people to randomly stab paramedics and young fathers and push women onto subway tracks.

Michael Shellenberger’s last piece for us was about how environmentalists in the West empowered Putin.

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