NYAPRS Note: Last week, NYS Attorney General Letitia James held a public hearing on New York’s mental health crisis and, in particular, the impact of the decline of both adult and youth inpatient psychiatric beds. The Attorney General’s objectives in this hearing were “to shed light on this crucial issue, explore potential areas of reform, and guide future investigations into allegations of inadequate mental health treatment….” Over the course of the 4+ hour hearing, the Attorney General also explored and endorsed a broad array of community based approaches that were emphasized within presentations by government leaders and rights and recovery advocates, including NYC Commissioner of Health and Mental Hygiene Dr. Ashwin Vasan, Disability Rights New York’s Sabina Kahn and NYAPRS’ Harvey Rosenthal. See the attached full testimonies and review the excerpts below. You can listen to the entire hearing testimony at https://ag.ny.gov/livestream/public-hearing-access-mental-health-care-new-york.
Ashwin Vasan, MD, PhD Commissioner
New York City Department of Health and Mental Hygiene
To begin the effort to fundamentally shift the way we care for these New Yorkers, we must start by shifting away from the idea that all people living with serious mental illness are simply moving from crisis to crisis and can only be helped with acute care and hospitalization. This perception has been created and perpetuated by the persistent lack of access to stable, community-based alternatives to care, treatment, and support, which are in and of themselves, a crisis preventive. Make no mistake, during a crisis, access to acute care resources is necessary. But we must shift towards a model of crisis prevention and long-term recovery in the community, and not simply in institutional settings. I find it helpful…to think about three fundamental pillars, or legs of a stool, that allow people to stand and find dignity and hope.
Those pillars are: housing, healthcare, and community.
We must ensure that people with Serious Mental Illness have permanent, affordable homes with health and social support services available through supportive housing.///…housing and healthcare do not advance sustained recovery unless paired with efforts to build community and to break social isolation for people with Serious Mental Illness, which is, ultimately, the driver of poor health and neglect. Recovery-oriented mental health systems rooted in community and connection, require investment in places where people can come together to break isolation, otherwise known as social infrastructure. Social infrastructure includes places where people can build community, end social isolation, and develop connections to vital services, to opportunity, and purpose for themselves. These places save lives, prevent crisis, and they serve to set people on paths to recovery and learning to live with a serious mental illness. And in all of this work, we are committed to meeting people where they are. Mental Health Clubhouses across our city also provide critical, long-term anchor institutions for people with Serious Mental Illness to build relationships, get access to resources, find employment and educational opportunities, and build a supportive peer community to help them navigate the ups and downs of living with a chronic and serious mental illness. We are excited about this unprecedented and renewed focus on mental health – particularly from the federal government – and have been working hand in hand with the Biden Administration and our State partners on these priorities, including the roll- out of the new national 988 crisis hotline.
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Sabina Kahn Staff Attorney Disability Rights New York
Attorney General Letitia James is correct: There is a mental health crisis in New York State. DRNY regularly hears as much from our clients and the communities we serve, including low-income children and families, incarcerated and formerly incarcerated people with mental illness, and people with disabilities who are unhoused or face housing instability—all of whom are being deprived of legally-mandated mental health care. When addressing this crisis, however, it is critical that the right questions are asked. The notice for this hearing placed particular attention on the difficulty that New Yorkers have in accessing inpatient services and noted the impact of COVID-19 on the mental health service system. We urge you to consider instead two different ways of framing New York’s mental health crisis. First, focus needs to be placed on the statewide challenges that people with mental illness have in obtaining community-based mental health services. While we agree that inpatient care should be available to New Yorkers who need it, far too many people are forced to seek this level of care after being denied access to community supports. We see the same crisis in the delivery of services to our children. Children who are not getting the help they need at home and in school are ending up in in-state and out-of-state facilities far away from their families. Adults and children are forced to seek out higher levels of care—or are forced into them—simply because the community-based services that they need (and have long needed) are unavailable. Counseling, intensive case management, community-based mental health crisis services, peer support services, psychiatrists, psychologists, and more all remain out of reach for far too many people who need them. New Yorkers have a federal right to receive services in the most integrated setting appropriate to their needs, and adults and children should never feel that, when it comes their mental health care needs—and, yes, even their intensive mental health service needs—that they have the option of inpatient hospitalization or having nothing at all. Investing in inpatient beds can never redress the longstanding failures to ensure that there is a robust and effective system for community-based mental health care in all parts of the state. Second, we urge all that participate today to recognize that New York State’s mental health crisis is not new. Nor was it created as a result of the COVID-19 pandemic…. Being honest about the causes of this crisis means looking at the State’s failures to invest in its communities. The lack of community-based mental health care for children and their families, adults, and older New Yorkers predates the pandemic; the State’s reliance on segregated settings to address the mental health service needs of adults and children in crisis predates the pandemic; the State’s failure to ensure that incarcerated people with disabilities receive the care and services they need and that people with disabilities are diverted from incarceration whenever possible predates the pandemic; and the use of deadly responses—such as law enforcement—as a substitute for true mental health crisis services predates the pandemic.
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Harvey Rosenthal CEO NY Association of Psychiatric Rehabilitation Service
….All public policies and services should be based on the fundamental belief that recovery should be the expectation for everyone, regardless of the extent of people’s current and past challenges. In doing so, we must ensure that people are afforded a full continuum of supports that runs the gamut of personalized outreach and engagement, crisis services, housing, peer to peer support, clubhouse and Medicaid funded psychiatric rehabilitation and treatment, emergency, inpatient and detox services.
…it is essential that we address the critical role that the social determinants of health play in promoting stability and community success, including the attainment of appropriate housing, financial stability related to employment and/or entitlements, culturally appropriate and responsive social relationships and support and appropriate access to transportation and food. In doing so, we must address the root factors that typically precede addressing the symptoms and struggle people currently face: homelessness, poverty, hunger, health inequities and racial, gender and other forms of discrimination.
Recommendations:
…Our ultimate focus has to be on improving discharge planning and follow up with a full continuum of community services. It is critical to understand that our success will not lie in building more hospital beds but in ensuring access to a well-functioning community-based system of services and supports. Every individual with a significant and repeat history of hospitalization should leave inpatient stays with a personalized peer bridger who stays involved with them for a period averaging 9 months, in keeping with the evidence based Critical Time Intervention model. We must dramatically increase our investments in what is called ‘low threshold housing’, programs that provide immediate access to harm reduction-based Housing First and Safe Haven models. We must dramatically accelerate our creation of a much more robust continuum of crisis services that features the use of the new 9-8-8 emergency hotline and follow along mobile crisis supports as needed. We must triple the number of newly planned crisis stabilization centers and, recognizing that these are only 24-hour interventions, create a continuum of step-down peer operated crisis supports, including 10-30 day respite and ‘living room’ programs. We must make major investments in mental health alternative to police first responders. While we will continue to offer appropriate training to police officers, ultimately our success will lie in sending out the right people to defuse a crisis and divert an avoidable altercation, arrest or tragedy. This must include the launching of Correct Crisis Intervention Today which are peer and EMT led models based on the 30-year success of Oregon’s CAHOOTs model. We must take racism head on and address our significant failure rates in engaging people of color as evidenced by the runaway rates of coercion and incarceration inflicted on these communities. This must include efforts to dramatically increase the number of agency administrator and direct care workforce who look and talk like the people they support. We must invest in new models of support that voluntarily not coercively engage people ‘hard to serve’ individuals. Our focus should not be on blaming them for our difficulties in engaging and supporting them. Accordingly, we should see a great increase in successful programs like the INSET program in Westchester County, whereby persistent efforts by peer staff (people in recovery who serve their peers) have engaged 80% of a cohort with major histories that would have otherwise subjected them to coercive practices. We should ensure the widespread use of psychiatric advance directives that can guide crisis care based on the preferences expressed by people when they are doing well that help them when they are not. Finally, we must continue to make huge investments in a linguistically and culturally competent workforce and the agencies in which they work..