Walk down the passage connecting the subway on 34th Street-Herald Square to a commuter line bound for New Jersey and you will almost certainly see people sleeping rough. The tunnel is a warm spot on a bitter January night. A team of police officers and psychiatric clinicians approach the sleepers to check how they are doing, and if they agree, transport them to a shelter. The clinician may also determine if they need more pointed help, whether they want it or not.
This is part of the city’s overnight homeless-outreach programme, Partnership Assistance for Transit Homelessness (PATH). They offer a bed, often giving the person a choice of borough and type of shelter. If a team determines someone might be in severe mental distress, and may be a danger to themselves or to others, their consent is not needed.
Involuntary commitment laws in New York state go back decades, but the idea fell out of favour after the closing of asylums. Over the past few years politicians in New York who were opposed have embraced it. Since 2022 Eric Adams, the city’s mayor, has instructed police and first responders to hospitalise people with severe mental illness who are incapable of looking after themselves. Kathy Hochul, the governor, has announced plans to “add more teeth” to the state laws on involuntary treatment and is promising more money. This builds on what is already happening in New York City.
Here a culture change is under way, says Brian Stettin, the mayor’s adviser on severe mental illness. “It’s just not going to be acceptable anymore to walk by people who are in a psychiatric crisis and are in desperate need of medical care.” It takes a lot to rattle New Yorkers. But seeing someone on the subway who is in distress, is not wearing shoes and may also be shouting profanities at passengers will do it. Straphangers have been shaken by attacks on the subway: at the end of January a homeless man shoved a woman into the path of a moving train; on New Year’s Eve security cameras recorded a man in Manhattan being shoved onto the tracks just as a train entered the station. Subway riders used to stand near the platform edge to quickly hop onto the train. Now they have taken to hugging the walls until the train arrives. Although subway crime has fallen and Mr Adams has deployed police to ride the rails overnight, the perception is different.
Mr Stettin says there are relatively few people who require involuntary care: the health department maintains three lists of 50 people who have been identified as the most challenging cases (he knows most by name). Police and clinicians also haul off other people if they are deemed a danger to themselves or others. Still, the number of people with severe mental illness ought to be manageable, and the programme can already point to successes.
About 150 people were taken off the subway last year under initiatives like PATH. Some now live in permanent supportive housing, others are in hospital, sometimes for as long as seven months. “At this point, it’s much more about proof of concept than huge numbers,” says Mr Stettin. Not everyone in severe distress meets the commitment criteria: some are in drug-induced psychosis. They will be diverted to other programmes. The officers The Economist accompanied as they worked with clinicians were kind to those in mental distress. Indeed, a few sought the police officers, not the nurse, for help.
New York is not alone in expanding involuntary treatment. California overhauled its system in 2022, creating a new civil-court system aimed at directing the mentally ill and homeless to treatment and housing. In a forthcoming paper Alex Barnard, a sociologist at New York University, found that the number of bills related to involuntary treatment introduced per year doubled between the 2011-12 legislative session and 2021-22. Criteria for commitment vary by state and it is difficult without evidence to determine which states have had better outcomes. Just changing the rules is not enough: San Francisco is now using laws that make involuntary commitment easier, but there are a lot of ill people living on the streets.
Helping the mentally ill while enhancing public safety is hard. “If your goal is to just have people not shouting on the subway, that’s different from if your goal is to deal with the unhoused,” says Mr Barnard. “But if your goal is a humanitarian impulse for a very small subset of people, then this approach makes more sense.” ■
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