Last Tuesday, New York Mayor Eric Adams announced an immediate expansion of an involuntary hospitalization policy in the city, alongside a harrowing legislative proposal aimed at peeling back many of the few legal and administrative barriers that prevent involuntary psychiatric commitments. In his administration’s announcement, the plan is billed as a “compassionate new vision” to address mental illness, invoking a “moral mandate” to “deliver for our most vulnerable.”
But in reality, this agenda is neither compassionate nor new. Instead, it marks a blatant backward shift in mental health care, and a push toward the era of mass institutionalization in state psychiatric hospitals. The policy reflects a growing wave of politicians, from California’s Governor Gavin Newsom to former president Donald Trump, who have openly embraced punitive and carceral frameworks for mental health services.
The central goal of Adams’s agenda is to undo “barriers to hospitalization”: the legal and administrative guidelines intended to keep people from being involuntarily hospitalized and thus removed from society against their will. Under an immediate guideline change, Adams has expanded the scope of behavior that could result in forced psychiatric evaluation from “likely to result in serious harm” to the much broader criteria that the individual “appears to be mentally ill, and displays an inability to meet basic living needs.” This change adds even further ambiguity, and a lower bar for justification, than the already contentious idea of how “harm” is judged in these cases. Worse, Adams has empowered police officers to make these initial judgements, which will undoubtedly lead to an increase in arrests and the subsequent funneling of people into institutionalization. Each of these changes would reinforce the same dynamic: It would become much easier for individuals to be arrested and forced into psychiatric evaluation against their will, and much easier for them to be involuntarily hospitalized for a long period of time.
Among other changes, Adams is pushing for mental health professionals working in homeless shelters to direct the removal of individuals from shelters into hospitalization. This would not only widen the sphere of professionals now empowered to compel people into psychiatric evaluation; it would also cause each basic interaction with shelter staff to be a risk for removal. While psychiatric evaluations are currently performed by physicians, Adams would also see that these determinations are made equally by psychologists, nurse practitioners, and social workers, who may not have the proper training to do so. Perhaps most alarmingly, Adams suggests that these psychiatric evaluations should include an individual’s ability to “adhere to outpatient treatment.” This would almost certainly mean that individuals would be judged simply for not having a health care plan.
To anyone with some knowledge of the asylum system, or the last half-century of disability rights movements, a sudden increase in the state’s capacity to institutionalize or incarcerate individuals is an ominous sign. Where criteria for involuntary hospitalization have been reduced, increases in psychiatric institutionalization have always followed.
Involuntary hospitalization has a long and fraught history. In the 19th century, individuals could be institutionalized with very little reason, often owing simply to small infractions of social norms. In our book Health Communism, we note that when the practice was at its peak, reasons for institutionalization included “novel reading,” “desertion by husband,” or simply, “politics.” Once institutionalized, many were incarcerated in psychiatric facilities for years, or indefinitely.
At its zenith in 1955, the US asylum system held 559,000 people, nearly as many people per capita as are currently detained under our current regime of mass incarceration. But that figure—over half a million people—only accounts for the peak number of individuals held at any one time. Over the course of that same year, at least 819,000 people cycled in and out of asylums, or died there.
In addition to the sheer scale of involuntary psychiatric detention, asylums were infamous for their horrible living conditions. Far from being sites of therapy or “rehabilitation,” asylums primarily functioned as sites to detain the mad and poor, removing them from society. These institutions were almost universally neglected and left to state austerity budgets. One doctor, who worked at the Willowbrook facility in Staten Island, characterized the institution as “this festering, purulent, wretched reality, this miserable, this violent, this savage way in which the State of New York is taking care of its own.”
Mayor Adams seems willfully ignorant of this history, just as he seems ignorant of the limits of New York’s currently existing mental health services. A centerpiece of Adams’s agenda is that once individuals have been removed from society and placed in involuntary hospitalization, they should then be transitioned to existing mental health services in their communities for ongoing care. According to one report, these very same services already have more than 1,000 people on waiting lists to access them in the first place. Given this reality, Adams’s agenda would likely result in mad, poor, and unhoused people being detained for long periods, creating a demand for more hospital beds or whole new facilities.
If this wasn’t enough of a reason to oppose the plan, Adams is seeking the expansion of involuntary hospitalization at a time when our health care system is overwhelmed after years of a pandemic. A recent report noted that some 850 psychiatric beds in New York City were shifted to Covid care early in the pandemic, and only half have been converted back. Underlying this is the fact that covid is not mentioned or considered in Adams’s plan at all. Arrest and involuntary hospitalization, like jailing individuals or holding them in congregate facilities of any kind, is a significant vector of covid transmission. Even if his long-term agenda fails, the immediate directives Adams has made will themselves lead to an increase in covid cases, putting the already-vulnerable people Adams wants to involuntarily hospitalize directly in harm’s way.
The irony of Adams’s plan is that many of the existing protections against involuntary hospitalization in New York State exist precisely because of the state’s dark history with institutionalization. While it must be said that the end of the asylum system—a process widely known as “deinstitutionalization”—remains incomplete, with the promise of “community care” never truly fulfilled, any movement in the opposite direction must be resisted.
We often think of psychiatric hospitals as a relic of the past (or, grotesquely, a Halloween attraction) but there is little reason to think they could not return under the impending policy shifts. Conservative media outlets have already called on Adams to build a new asylum, and in 2021, in an appearance on MSNBC’s Morning Joe, Adams himself called the closure of the notorious Willowbrook facility “a mistake” and an “overreaction.” New York Governor Kathy Hochul has already committed to support for additional hospital beds to support Adams’s agenda. And as abolitionists have long warned, we can expect that if they build it, they will fill it.
The benefit of understanding the history of asylums and the incomplete history of deinstitutionalization is that we know what is needed—even if Adams can’t see it. As many have pointed out, Adams’s agenda would give police the freedom to sweep the streets and subways of unhoused people. This is nothing but punishment, doled out to individuals for their crime of living in a society that does not guarantee housing for all. At the same time, people who desperately need health care—of any kind, including mental health care or, especially, long-term care or long-term services and support—are entitled only to the health care they can buy. Activists, particularly the disabled, the mad, and their comrades, have been demanding changes to state and federal policies for years. These would actually address what Adams calls the “moral mandate” to “deliver for our most vulnerable.” It’s time we listen to them.