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New York's Directive 
for Mental Health 
Involuntary Removals:
The Intersectional  
Risk for Unhoused 
New Yorkers with a 
Serious Mental Illness

LANYA SNYDER



4  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS

ABSTRACT

Behavioral health care, more commonly known as psychiatric care, has 
been a longstanding and complex issue, especially for marginalized New 
Yorkers. Healthcare policy addressing and caring for people diagnosed 
with a serious mental illness is fundamental to basic human rights; at the 
same time, it is a nuanced matter. Policies surrounding economic issues 
of poverty and housing instability are inextricably linked to social issues 
of mental and physical healthcare. 

Healthcare policy and the experience of homelessness are closely 
SPURLK�MVY�[^V�YLHZVUZ!�ÄYZ[��[OL�OPNO�JVZ[�VM�OLHS[OJHYL�JVU[YPI\[LZ�[V�
poverty for many Americans; and second, the poor and the aging are 
[OL�TVZ[�SPRLS`�[V�Z\ɈLY�MYVT�PSSULZZ�HUK�OPNO�TLKPJHS�L_WLUZLZ��4HY[PU��
2015). This paper will consider the intersectional risk for unhoused 
New York City residents with a serious mental illness in light of Mayor 
Eric Adams’ recent directive for Mental Health Involuntary Removals. 
This new directive enables authorities to forcibly transport unhoused 
New Yorkers to hospitals to remove them from public areas. Although 
the current mayoral administration frames this as a moral obligation 
to act on behalf of New Yorkers with a serious mental illness, it is far 
MYVT�HU�LɈVY[�[V�LUZ\YL�[OH[�L]LY`VUL�OHZ�OV\ZPUN�HUK�YLJLP]LZ�IHZPJ�
healthcare. Adams’ misguided policy is a veiled attempt to make the city 
HWWLHY�ZHMLY�^OPSL�KVPUN�SP[[SL�[V�HZZPZ[�[OVZL�^OV�HYL�Z\ɈLYPUN�HUK�MHPSZ�
[V�HKKYLZZ�PU[LY]LU[PVUZ�MVY�[OL�YLHS�PZZ\L�H[�OHUK!�OV\ZPUN�



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   5   

LANYA SNYDER

O
n the morning of January 15, 2022, Michelle Go, a 40-year-
old Chinese-American, was fatally pushed onto the subway 
[YHJRZ�H[�;PTLZ�:X\HYL��4HY[PHS�:PTVU��[OL�PUKP]PK\HS�^OV�
committed this unprovoked act, emigrated to New York 

from Haiti in his teens and had been experiencing homelessness for 
the past 18 years. He also has a longstanding history of schizophrenia, 
including approximately 20 prior hospitalizations. Go’s death is sadly not 
[OL�ÄYZ[�VM�P[Z�RPUK��5L^�@VYR�OHZ�Z[Y\NNSLK�[V�LUHJ[�LɈLJ[P]L�SLNPZSH[PVU�
governing the treatment of individuals with a chronic serious mental 
illness (SMI) and, as a result, thousands of New Yorkers like Simon elude 
[YLH[TLU[��+P]LU���������(�:40�PZ�KLÄULK�I`�[OL�5H[PVUHS�0UZ[P[\[L�MVY�
Mental Health (NIMH) as a mental, behavioral, or emotional disorder 
resulting in serious functional impairment, which substantially interferes 
with or limits one or more major life activities (Mental Illness, n.d.).

The timing of this violence impacted the political response. This tragedy 
occurred when hate crimes targeting Asian Americans were on the rise, 
and although police concluded that this particular incident was not 
racially motivated and there was no known prior connection between 
Go and Simon, the larger sociopolitical context may have fueled the 
HKTPUPZ[YH[PVU�Z�ULLK�[V�YLZWVUK��PU�VYKLY�[V�LUZ\YL�W\ISPJ�Z\WWVY[��
This particular incident happened following a slew of incidents in which 
people were pushed onto subway tracks, though none of the previous 
had been fatal. As of mid-March 2022, transit crime was up 80.3% 
compared with the same period in 2021, though this number may be 
ZRL^LK�ILJH\ZL�VM�KLJYLHZLK�Z\I^H`�YPKLYZOPW�K\YPUN�[OL�ÄYZ[�`LHY�
of the Covid-19 pandemic (Gelinas, 2022). It also occurred during Eric 
(KHTZ»�ÄYZ[�^LLR�HZ�TH`VY��;OPZ�[PTPUN�HTWSPÄLK�PZZ\LZ�VM�YHJPHSS`�
driven hate crimes, random acts of violence, and a perceived surge 
in subway crime, and it provided linkage to the deep-seated issues 
VM�\UOV\ZLK�5L^�@VYRLYZ�^P[O�TLU[HS�PSSULZZ��ZWLJPÄJHSS`�[OVZL�^P[O�
persistent and often treatment-resistant SMI. 



6  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

Leaders in the public and private sectors have worked for decades 
to propose policies for those who struggle with homelessness and 
mental illness. Hospitalization rates for New Yorkers living with a SMI 
are consistently higher than the national average (Heun-Johnson et al., 
2018). While the percentage of people with a SMI is a much smaller 
subset than those living with any mental illness, New York City has a 
disproportionately higher number of its population diagnosed with a SMI 
compared to the national average and fewer resources to treat those 
needing inpatient psychiatric care. 

Go’s death garnered widespread media attention and was the catalyst 
for The Subway Safety Plan, a reaction outlined by the Adams 
administration the month after the incident. This was followed by the 
Mental Health Involuntary Removal (MHIR) policy directive, announced 
later in 2022. 

Multifaceted sociopolitical issues in which mental health is just one 
KPTLUZPVU�LUHISL�WVSP[PJPHUZ�[V�JP[L�TLU[HS�OLHS[O�HZ�HU�V]LYZPTWSPÄLK�
Q\Z[PÄJH[PVU�^OPSL�VTP[[PUN�V[OLY�JVU[YPI\[PUN�MHJ[VYZ�[OH[�HYL�UV[�HZ�
politically compelling. Adams’ MHIR response to the issues at the 
MVYLMYVU[��^OV�P[�HɈLJ[Z��HUK�OV^�P[�^PSS�IL�PTWSLTLU[LK�HTV\U[�[V�
UV[OPUN�TVYL�[OHU�JVTWHZZPVUH[L�^PUKV^�KYLZZPUN�PU�HU�LɈVY[�[V�
HWWLHY�[V\NO�VU�JYPTL��<ZPUN�W\ISPJ�ZHML[`�HZ�Q\Z[PÄJH[PVU��P[�WVPU[Z�
[OL�ÄUNLY�H[�\UOV\ZLK�PUKP]PK\HSZ�^OV�TH`�OH]L�HU�\U[YLH[LK�TLU[HS�
illness. If, as Adams says, preventing unhoused New Yorkers from living 
on city streets or in subway stations and “helping them heal” is the city’s 
objective, forcibly transporting them to an Emergency Department (ED) 
KVLZ�SP[[SL�[V�ZVS]L�[OL�PZZ\L�VM�OV\ZPUN��(KHTZ����������!����

MENTAL HEALTH INVOLUNTARY REMOVALS (MHIR)

Racial and ethnic minorities and immigrant populations in New York 
*P[`�OH]L�ZPNUPÄJHU[S`�SLZZ�HJJLZZ�[V�Z[HISL�OV\ZPUN��SP]HISL�^HNLZ��HUK�
physical and mental health resources compared to majority groups, 
W\[[PUN�[OLT�H[�H�OPNOLY�YPZR�MVY�HK]LYZL�TLU[HS�OLHS[O�JVUZLX\LUJLZ�
in the wake of traumatic experiences (Rudenstine et al., 2020). On 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   7   

November 28, 2022, Adams announced his directive to remove 
unhoused individuals from the street and treat their SMI. What was 
omitted in both Adams’ speech and the policy is that not all unhoused 
individuals have a SMI and there are often co-occurring determinants 
[OH[�ULNH[P]LS`�PTWHJ[�[OL�WVW\SH[PVU�VM�PUKP]PK\HSZ�^P[O�:40!�YHJPHS�
discrimination, employment status, familial or community support 
systems, comorbidities, co-occurring psychological disorders, and 
a person’s health insurance or lack thereof. These are in addition to 
housing, the social determinant most closely linked to the MHIR policy 
directive. 

-VY�JVU[L_[��VUL�T\Z[�ÄYZ[�\UKLYZ[HUK�[OL�L_PZ[PUN�5L^�@VYR�:[H[L�
Mental Hygiene Laws. Article 9 of the Mental Hygiene Law (MHL) 
is legislation from the New York State Senate (2021) that sets 
MVY[O�Z[HUKHYKZ�HUK�WYVJLK\YLZ�MVY�WH[PLU[Z�^OV�YLX\PYL�PUWH[PLU[�
hospitalization for a mental illness. The policy outlines emergency 
assessment for immediate observation, care, and treatment, powers 
VM�JLY[HPU�WLHJL�VɉJLYZ�HUK�WVSPJL�VɉJLYZ��[YHUZWVY[�MVY�L]HS\H[PVU��
and powers of approved mobile crisis outreach teams (Mental Health 
Involuntary Removals [MHIR], 2022). 

The directive for MHIRs augments Article 9 of the MHL by outlining roles 
HUK�YLZWVUZPIPSP[PLZ�MVY�PU]VS\U[HY`�YLTV]HSZ��(JJVYKPUN�[V�[OL�6ɉJL�
of Mental Health’s (OMH) directive, sections 9.41 and 9.59 of the MHL 
authorize the removal of a person who appears to be mentally ill and 
displays an inability to meet their basic living needs (MHIR, 2022). The 
relaxed language of the MHIR authorizes the removal of a person by 
force and involuntary transport to the closest hospital for a psychiatric 
evaluation, “even when no recent dangerous act has been observed” 
�4/09��������W������;OL�Ä]L�WHNL�4/09�WVSPJ`�LUKZ�HM[LY�V\[SPUPUN�]HN\L�
WYV[VJVSZ�MVY�PU]VS\U[HY`�OVZWP[HS�[YHUZMLYZ�^P[O�YLZWLJ[�[V�KPɈLYLU[�
agencies tasked with enforcing this directive. The scant guidelines are 
L_WYLZZLK�^P[O�V]LY�ZPTWSPÄLK�SHUN\HNL�JVTWHYLK�[V�^OH[�OHZ�HS^H`Z�
been standard ED or Comprehensive Psychiatric Emergency Program 
�*7,7��WYVJLK\YL�MVY�YLJLP]PUN�OLHS[OJHYL�MHJPSP[PLZ!�[HRL�YLZWVUZPIPSP[`�

LANYA SNYDER



8  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

for the individual in the hospital, obtain collateral information, complete 
a comprehensive psychiatric evaluation for the removed individual, and 
a psychiatrist evaluates the individual for admission (MHIR, 2022). 

There is no outline in the MHIR for how a person, once removed from 
public areas and taken to a hospital, would receive long-term treatment 
for an ongoing SMI or related social determinants. Nor is there any 
guidance or resources if they are not admitted to the hospital and return 
to the streets. For individuals who meet the criteria to receive treatment 
through inpatient hospitalization, the MHIR fails to address what 
happens once a person is discharged. The crisis of care—as in the case 
VM�4Y��:PTVU��^OV��HJJVYKPUN�[V�2H\MTHU���������YLJLP]LK�Ä]L�TVU[OZ�
of inpatient treatment at the Bronx Psychiatric Center before discharge 
in July of 2021— is not an issue of whether New York hospital systems 
can compassionately treat someone experiencing a SMI. Medical 
facilities can and do stabilize hundreds of psychiatric patients every 
day. The gaping hole is an omission of policy that should but does not 
HKKYLZZ�[OL�JVU[PU\\T�VM�JHYL��PUJS\KPUN�LɈLJ[P]L�OV\ZPUN�ZVS\[PVUZ�MVY�
New Yorkers with a SMI.

INSTITUTIONS AFFECTED BY THE MHIR DIRECTIVE

Hospital-based emergency care is the only medical treatment to 
which Americans have a legal right regardless of their ability to pay 
(Barish et al., 2012). Whether a particular hospital operates under 
public or private auspices is of critical importance in determining who 
YLJLP]LZ�WZ`JOPH[YPJ�ZLY]PJLZ�HUK�OV^�[OVZL�ZLY]PJLZ�HYL�ÄUHUJLK��
Hospitalization rates for New Yorkers living with a SMI are consistently 
higher than the national average (Heun-Johnson et al., 2018). It is widely 
accepted that psychiatric units generate less revenue for healthcare 
Z`Z[LTZ�JVTWHYLK�[V�Z\YNPJHS�\UP[Z"�[O\Z��PU�JVUZPKLYH[PVU�VM�ÄUHUJPHS�
pressures, private hospitals divert psychiatric patients to city public 
hospitals (Mueller, 2017). Unhoused New Yorkers are more likely to 
receive treatment through the city’s public hospital systems.

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   9   

OTHER RELEVANT PUBLIC POLICIES 
THE SUBWAY SAFETY PLAN

The MHIR is an extension of the memorandum published on February 
18, 2022 by the OMH known as the Subway Safety Plan. This was the 
ÄYZ[�KPYLJ[P]L�MYVT�[OL�(KHTZ�HKTPUPZ[YH[PVU�MVY�WVSPJL�HUK�V[OLY�VɉJPHSZ�
to remove any person with a mental illness or any person who appears 
to be mentally ill, even when there is no recent dangerous act, and 
transport them to a hospital for a psychiatric evaluation. This lengthier 
WVSPJ`�X\HSPÄLZ�[OL�YH[PVUHSL�MVY�LUMVYJLTLU[��Z[H[PUN�[OH[�¸OVTLSLZZULZZ�
in NYC has reached the highest levels since the Great Depression” 
�6ɉJL�VM�4LU[HS�/LHS[O�B64/D�L[�HS���������W������>OH[�PZ�JVUZWPJ\V\Z�
PZ�[OL�JP[`»Z�YH[PVUHSL�MVY�^O`�[OPZ�WVW\SH[PVU�PZ�H[�YPZR!�¸JOYVUPJHSS`�
homeless individuals with SMI often have symptoms and cognitive 
KPɉJ\S[PLZ�[OH[�JVU[YPI\[L�[V�KPɉJ\S[PLZ�HJJLZZPUN�[YLH[TLU[�HUK�OV\ZPUN�
resources” (OMH et al., 2022, p. 2). Furthermore, the alternative agenda 
OLYL�PZ�OPKPUN�PU�WSHPU�ZPNO[��(KHTZ�Q\Z[PÄLK�[OPZ�HNNYLZZP]L�SHUN\HNL�
to augment existing sections of the MHL under the guise of a moral 
obligation to help unhoused New Yorkers in need of mental healthcare, 
^OPSL�ZPT\S[HULV\ZS`�\ZPUN�P[�[V�X\LSS�W\ISPJ�ZHML[`�JVUJLYUZ�HIV\[�JYPTL�
on the street and in the subway system.

MHL SECTION 9.60, KNOWN AS KENDRA’S LAW

After Go’s death, Adams pointed to New York MHL section 9.60, better 
known as Kendra’s Law, which assertively connects New Yorkers 
experiencing a mental health emergency to medical treatment. Section 
9.60 was named after Kendra Webdale, who died in January 1999 
when she was pushed in front of a NYC subway train by a person with 
untreated schizophrenia (Pataki et al., 2005). Similar to Go’s case, the 
man who pushed Webdale had just been released from a psychiatric 
hospital, and his actions resulted from medication non-compliance 
(Diven, 2022). Soon thereafter, in 1999, New York passed legislation to 
provide court-mandated Assisted Outpatient Treatment (AOT). This is a 
more humane and less restrictive alternative to inpatient commitment for 

LANYA SNYDER



10  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

those who are unlikely to survive safely in the community without court-
mandated supervision (Pataki et al., 2005). Per the U.S. Department of 
Justice (2022), AOT programs are also responsible for the oversight and 
monitoring of service providers, including case management services or 
Assertive Community Treatment (ACT) team services. Case managers 
and ACT team members follow an AOT recipient’s level of compliance 
and delivery of services by other providers pursuant to the court order 
(U.S. Department of Justice [DOJ], 2020).

ASSISTED OUTPATIENT TREATMENT (AOT) EVALUATION 

More than two decades have passed since the enactment of section 
9.60 under New York’s MHL. Critics of AOT argue that court mandated 
medical compliance infringes on civil liberties and disproportionately 
targets people of color. Others have studied the results and praised 
P[Z�LɈLJ[P]LULZZ�PU�YLK\JPUN�OHYT�[V�PUKP]PK\HSZ�HUK�JVTT\UP[PLZ��
Appelbaum (2005) reviewed more than 10,000 New Yorkers who were 
YLMLYYLK�[V�(6;�K\YPUN�[OL�Ä]L�`LHY�ZWHU�HM[LY�P[�^HZ�ÄYZ[�LUHJ[LK��
Of the referrals, 93% of cases were granted court-ordered AOT. In 
evaluating participation, Appelbaum’s (2005) study examined the history 
of the individuals granted AOT for three years prior to their court-ordered 
AOT. It found that 97% had been previously hospitalized, 30% were 
arrested, 23% were incarcerated, and 19% were unhoused. Even more 
LUJV\YHNPUN�^LYL�V\[JVTLZ�HZZLZZLK�V]LY�Ä]L�`LHYZ�HM[LY�THUKH[LK�
treatment, which showed a 44% decrease in general harmful behaviors, 
including a 47% decrease in physical harm to others (Appelbaum, 2005). 
Furthermore, arrests, incarceration, psychiatric hospitalization, and 
homelessness collectively dropped by 74 to 87% (Appelbaum, 2005).

AOT CRITICISM

Kaufman (2023) notes that when Simon left the hospital in July of 2021, 
social workers escorted him to a supportive housing apartment building 
in the Bronx, where he could live with on-site services. They left him 
with a 30-day supply of medication and a next-day appointment with 
a psychiatrist. Mr. Simon never showed up to his outpatient psychiatry 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   11   

appointment and is believed to have spent no more than two hours in 
OPZ�UL^�OVTL�^OLYL�OL�SLM[�VUS`�H�[YHJL�VM�OPZ�WYLZLUJL!�H�IYV^U�WHWLY�
IHN�Z[\ɈLK�^P[O�[OL�Z\WWS`�VM�TLKPJH[PVUZ��2H\MTHU���������(6;�PZ�
not a life sentence; court orders can lapse after six months. The most 
MYLX\LU[S`�JP[LK�YLHZVU�MVY�UVU�YLUL^HS�VM�JV\Y[�VYKLYZ��HJJVYKPUN�[V�[OL�
NYS-OMH, is that the individual has improved and is no longer in need 
of court-ordered services. The paradox is that people likely improved 
because they were mandated to comply with medication, as was the 
case for Simon. According to Simon’s sister, treatment and medicine 
kept him going, and once he no longer posed a threat to himself or 
V[OLYZ��[OL�JV\Y[�UV�SVUNLY�YLX\PYLK�OPT�[V�[HRL�OPZ�TLKPJPUL��+P]LU��
2022). Left to his own devices, he stopped taking his medication and his 
delusions resumed. 

�9HJPHS�KPZWHYP[PLZ�WLY]HKL�5L^�@VYR�Z�(6;�WYVNYHT��^P[O�)SHJR�HUK�
Hispanic people disproportionately subjected to its court orders. 
Because of this, AOT programs have arguably further marginalized and 
discriminated against New Yorkers of color (Rodríguez-Roldán, 2020). 
During Adams’ 2022 announcement, he called to make it easier to 
enforce Kendra’s Law as a means to improve ongoing mental health 
outpatient treatment compliance for those who cannot meet their needs 
V\[ZPKL�VM�PUZ[P[\[PVUZ��5L^�@VYR�4/3� �����V\[SPULK�I`�1HɈL����� ���
stipulates that once a patient meets the threshold for AOT eligibility, 
almost any person associated with that individual can petition for court-
ordered treatment. While hospital providers can and do apply for AOT, 
(KHTZ��Z[H[LTLU[�PZ�TPZSLHKPUN��HZ�P[�Z\NNLZ[Z�2LUKYH»Z�3H^�JHU�VUS`�
be mandated through hospitalization. In fact, the petition can be initiated 
by any mental health providers, directors of community programs, 
Z\WWVY[P]L�OV\ZPUN�KPYLJ[VYZ��WHYVSL�VY�WYVIH[PVU�VɉJLYZ��VY�HU`�ZVJPHS�
service designee working with the individual. Furthermore, AOT is not 
an under-utilized resource as Adams also infers. According to Rascoe 
and Lewis (2022), as of October, there was an 800-person waiting list 
for those eligible for AOT. Without additional funding for this supportive 
service, forcing AOT creates a bottleneck for outpatient behavioral 
healthcare supportive services in the community. 

LANYA SNYDER



12  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

>OPSL�2LUKYH»Z�3H^�JHU�IL�ILULÄJPHS�MVY�[OVZL�^OV�KV�YLJLP]L�(6;��
Diven (2022) outlines its pitfalls. It fails to address the population at 
large, because it does not account for those who are not a threat to 
themselves or others. Furthermore, the legal statute for obtaining a 
court order is based on prior acts demonstrating dangerousness and 
treatment non-compliance, which imposes a high burden of proof. 
A widespread misconception is that people who are hospitalized for 
psychiatric stabilization are simply discharged to the streets without 
shelter, follow-up outpatient care, medications, or other supportive 
services. According to a study of psychiatric inpatient discharge 
practices and aftercare appointments in New York State, Smith et al. 
(2017) concluded that hospital providers, including social workers, 
reported having scheduled appointments for ongoing follow-up 
treatment for 85% of patients prior to discharge. The percentage of 
those found not to have psychiatric outpatient services were patients 
associated with having a co-occurring substance use disorder or other 
comorbid condition that took priority. This does not account for other 
social services secured for these patients in discharge planning. This 
study examined associations between routine discharge planning 
WYHJ[PJLZ�HUK�[PTL�[V�[YLH[TLU[�MVSSV^�\W�HM[LY�KPZJOHYNL��ÄUKPUN�[OH[�
45% of adults did not attend an initial aftercare appointment within 30 
days of discharge (Smith et al., 2017). The data illustrates a void in the 
continuum of care needed for outpatient support, such as intensive case 
management and services through ACT teams, during the transition 
from the inpatient setting to supportive housing.

STAKEHOLDERS 

For the MIHR directive, stakeholders include community members, 
SH^�LUMVYJLTLU[�VɉJPHSZ��OLHS[OJHYL�^VYRLYZ�HUK�HKTPUPZ[YH[VYZ��
lawmakers, and New York City residents. New Yorkers with a SMI are 
WYPTHY`�Z[HRLOVSKLYZ��JVUZPKLYPUN�[OPZ�WVSPJ`�KPYLJ[S`�HɈLJ[Z�[OLPY�ZVJPHS�
welfare. At present, it is estimated that 250,000 adults have a SMI, 
or 3% of the total population in New York City. Among the unhoused 
population, which totals about 60,000 living in city shelters or on the 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   13   

Z[YLL[Z��[OL�504/»Z�5L^�@VYR�JOHW[LY�LZ[PTH[LZ�[OH[�VUL�PU�Ä]L�[V�VUL�
in six people live with a SMI (Kaufman, 2023). While the percentage of 
WLVWSL�^P[O�H�:40�PZ�ZPNUPÄJHU[S`�ZTHSSLY�[OHU�[OVZL�SP]PUN�^P[O�V[OLY�
mental illnesses, New Yorkers with a SMI are disproportionately visible 
in the community given the longstanding systemic failures and lack of 
continuity in care.

SOCIAL DETERMINANTS FOR PRIMARY STAKEHOLDERS

In addition to the linkage between poverty and housing insecurities, 
it should also be noted that much of the population in need of urgent 
psychiatric care already face racial stigma, injustice, and other 
VWWYLZZP]L�Z`Z[LTPJ�MVYJLZ��;OPZ�WVW\SH[PVU�TH`�Z\ɈLY�MVY�`LHYZ�^P[OV\[�
ILPUN�[YLH[LK��HUK�[OLU�VM[LU�KV�UV[�OH]L�HɈVYKHISL�MVSSV^�\W�JHYL�VY�
access to costly prescriptions. Many unhoused patients with a SMI also 
Z\ɈLY�MYVT�JVTVYIPKP[PLZ�Z\JO�HZ�Z\IZ[HUJL�HI\ZL��^OPJO�PZ�[V�ZH`�[OH[�
even if medication and therapeutic treatments are to stabilize the mental 
PSSULZZ��[OLZL�5L^�@VYRLYZ�Z[PSS�MHJL�HɊPJ[PUN�OLHK^PUKZ��3VUNZ[HUKPUN�
failures to address oppressive social determinants are why people 
often end up back in the ED or CPEPs mere days after discharge from 
inpatient care. The lack of funding and resources for the continuum of 
care including housing—that is not predicated on drug testing, curfews, 
or a lapse in mental health care—exacerbates the syndemics of 
homelessness and mental illness.

THE PROBLEM: NEW YORK CITY’S CURRENT  
MAYORAL STANCE

New York City is facing a crisis as those in power are using people 
L_WLYPLUJPUN�OVTLSLZZULZZ��TVYL�ZWLJPÄJHSS`�[OVZL�^P[O�H�:40�VY��
now, even a perceived mental illness, as a means to ensure public 
safety. Politicians like Adams, a former NYPD Captain, turn to policing 
as a means to remove the unhoused from the streets. Friedman (2022) 
HYN\LZ�[OH[�WVSP[PJPHUZ�JVUÅH[L�PZZ\LZ�VM�OVTLSLZZULZZ�HUK�[OL�ULLK�
for public safety, utilizing law enforcement to unfairly target people 

LANYA SNYDER



14  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

who are unhoused to ensure public safety. He points to how laws, 
particularly those in urban areas that wrest the “out of sight, out of 
mind” mantra, lessen public concerns for safety. There is an exhaustive 
list of legislation to keep those experiencing homelessness out of 
sight, including laws against living in public spaces, camping in cities, 
vagrancy and loitering, begging and panhandling, and sleeping in public. 

 In the policy’s original version, Adams claimed people with mental 
illness were largely responsible for an increase in subway crime, despite 
data suggesting most crimes were not committed by unhoused or 
mentally ill New Yorkers (Fitzsimmons & Newman, 2022). The only 
X\HSPÄJH[PVU�MVY�YLTV]HS��HJJVYKPUN�[V�[OL�4/09�KPYLJ[P]L��PZ�[OH[�[OL�
WLYZVU�PU�X\LZ[PVU�JHUUV[�TLL[�[OLPY�IHZPJ�ULLKZ��H�Q\KNTLU[�LU[PYLS`�
subjective and in the hands of those tasked with the person’s removal.

CRITIQUES AND CONSIDERATIONS 

The MHIR is an attempt to outstrip laws that already exist for people 
experiencing a psychiatric emergency in public, through its directive that 
police and emergency responders simply remove individuals from the 
streets and transport them to a hospital, whether or not the individual 
WVZLZ�H�KHUNLY�[V�[OLTZLS]LZ�VY�[V�V[OLYZ��:\WLYÄJPHSS �̀�[OPZ�PTWSPLZ�
[OH[�HSS�WLVWSL�^P[OV\[�WLYTHULU[�OV\ZPUN�T\Z[�Z\ɈLY�MYVT�HU�\U[YLH[LK�
TLU[HS�PSSULZZ�HUK�HYL�]PVSLU[�PUKP]PK\HSZ��0U�HKKP[PVU�[V�[OPZ�ÅH^LK�
presumption, politicians such as Adams cite morality and responsibility 
to disguise policing as a means of confronting longstanding problems, 
instead of addressing the root causes of homelessness through 
substantive policy changes. The New York City Civil Liberties Union 
(NYCLU) has been a vocal critic of MHIR and believes this directive 
violates fundamental legal rights for people living with any mental illness. 
The National Alliance on Mental Health (NAMI) has been critical, too, 
suggesting involuntary detention does not solve the issue of supportive 
housing for those with any mental health crisis. Adams points to 
court ordered AOT as a successful law that should be enforced, yet 
is misleading regarding how this essential component of a functional 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   15   

public mental health system can be implemented and to whom it applies 
(Subway Safety Plan, 2022).

Admittedly, the 2019 NYS-OMH data for all inpatient New York 
*P[`�WZ`JOPH[YPJ�MHJPSP[PLZ�ZOV^�[OH[�VUL�PU�Ä]L�������WH[PLU[Z�^LYL�
readmitted within 30 days, and nearly one in three (33%) were 
YLHKTP[[LK�^P[OPU� ��KH`Z��([�Ä]L�JP[`�OVZWP[HSZ��[OL� ��KH`�WZ`JOPH[YPJ�
YLHKTPZZPVU�YH[LZ�^LYL�ZPNUPÄJHU[S`�OPNOLY��YHUNPUN�MYVT�����[V�
64%. Similar rates exist for those presenting to EDs departments for 
psychiatric symptoms soon after inpatient discharge. On the surface, 
P[�PZ�LHZ`�MVY�WVSP[PJPHUZ�[V�WVPU[�[OL�ÄUNLY�H[�OLHS[OJHYL�Z`Z[LTZ��
when in actuality the data points to a system that relies on short-term 
[YLH[TLU[�VM�WZ`JOPH[YPJ�Z`TW[VTZ�YH[OLY�[OHU�HKLX\H[LS`�HKKYLZZPUN�
long-term supportive care and social determinants for people with 
a SMI (Nortz, 2021). There is no formal healthcare policy, much less 
detailed plans or proposed guidance for actual treatment in the MHIR 
other than a psychiatric evaluation. This policy does not acknowledge, 
let alone propose, solutions that largely contribute to why unhoused 
people do not have access to healthcare. And for those who do receive 
ZVTL�PUWH[PLU[�[YLH[TLU[�[OYV\NO�OVZWP[HSPaH[PVU��[OLYL�HYL�PUHKLX\H[L�
resources for the post-discharge continuum of care, which is essential 
for sustaining remission from chronic illness. 

Opponents of the mayor’s MHIR policy say not enough attention is 
KPYLJ[LK�[V^HYKZ�HJJLZZPISL�HUK�HɈVYKHISL�OV\ZPUN�HUK�OLHS[OJHYL��-VY�
decades, unhoused New Yorkers have been brought to EDs by NYPD 
and EMS every night. In response to Adams’ plan, many psychiatrists 
say this will not come close to solving the problem of untreated mental 
illness among those living on society’s margins (Goldstein, 2022). 
/VZWP[HSZ�HYL�UV[�H�WSHJL�[V�MVYJPIS`�[YHUZWVY[�HUK�VɊVHK�WLVWSL�ZPTWS`�
to remove them from the streets. Adams fails to acknowledge the long-
term resources needed to address the interconnected medical and 
housing issues this policy directive purports to solve. When treating 
someone with a SMI there is a disproportionate emphasis on symptom 
reduction using drug therapies and psychotherapy and not enough 

LANYA SNYDER



16  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

attention and resources for the continuum of care that is practical and 
HɈVYKHISL��;OL�TLU[HS�OLHS[O�JYPZPZ�JP[LK�I`�WVSP[PJPHUZ�PZ�UV[�Z[YPJ[S`�
medical; the path to healing also involves interventions to address 
the social determinants. Without ongoing follow-up appointments, 
supportive care, and rehabilitative services including housing, several 
days or even a few weeks of psychiatric hospitalization do little to break 
the cycle of chronic homelessness and SMI.

SOLUTION: HOUSING REFORM 

The solution to the issue at the core of this crisis is to reform housing 
policies. Social workers join other providers and advocates in lamenting 
the lack of service integration and the scarcity of resources available for 
adults who are experiencing comorbidities of homelessness and mental 
illness (Padgett et al., 2006). However, studies have consistently found 
that only about 25%–30% of unhoused people have a SMI (Padgett, 
2020). In just a handful of days, if a person receives proper nutrition, 
sleep regulation, social support, and consistent medication, their 
behavior changes and psychiatric symptoms diminish. During the public 
announcement for the Subway Safety Plan, Adams said, “It is cruel and 
inhumane to allow unhoused people to live on the subway, and unfair 
to paying passengers and transit workers who deserve a clean, orderly, 
and safe environment” (2022, February 18). If the mayor believes this, 
then the administration should consider redirecting resources toward 
policies that connect people with community-based systems such as 
ACT teams and adopt Housing First (HF) policies.

 New York City relies on an overcrowded shelter system and a 
[YLH[TLU[�ÄYZ[�HWWYVHJO��^OPJO�YLX\PYLZ�\UOV\ZLK�PUKP]PK\HSZ�^P[O�H�
:40�[V�JVTWSL[L�H�ZLX\LUJL�VM�Z[LWZ�[V�KLTVUZ[YH[L�YLHKPULZZ�MVY�
supportive housing. HF is a departure from this linear continuum of 
care model by providing immediate access to housing in independent 
HWHY[TLU[Z��;OPZ�L]PKLUJL�IHZLK�OV\ZPUN�WVSPJ`�VɈLYZ�[LUHU[Z�HU�
array of services through interdisciplinary ACT teams consisting of 
social workers, psychiatrists, vocational trainers, and substance 

NEW YORK’S DIRECTIVE FOR MENTAL HEALTH INVOLUNTARY REMOVALS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   17   

HI\ZL�JV\UZLSVYZ��7HKNL[[�L[�HS����������/-�KVLZ�UV[�YLX\PYL�WLVWSL�
experiencing homelessness to address their behavioral health or 
substance use before providing housing. The policy is predicated on 
the philosophy that housing is the foundation on which people can 
recover. Additionally, studies have consistently shown access to housing 
generally results in cost savings for communities because housed 
people are less likely to use emergency services such as hospitals, 
jails, and emergency shelters (National Alliance to End Homelessness 
[NAEH], 2022). Waiting for individuals to receive and comply with 
medical treatment for a SMI, then rewarding them with housing, 
perpetuates the never-ending cycle of homelessness, institutionalization, 
and incarceration. In short, it solves neither the housing nor the mental 
health crisis.

During his MHIR address, Adams said his administration had a moral 
obligation to help [New Yorkers] who “cycle in and out of hospitals and 
jails, and New Yorkers rightly expect our city to help them and help 
[OLT�^L�^PSS¹��(KHTZ���������!�����0YVUPJHSS �̀�H�TLYL�[OYLL�^LLRZ�ILMVYL�
this speech, data was released showing that nearly 2,600 supportive 
housing apartments were vacant, which is enough to house the 
estimated 3,400 people living in streets or subways (Newman, 2022). 
According to Brand (2022), the city launched a new pilot program in 
early September of 2022, moving 80 formerly unhoused New Yorkers 
into vacant supportive housing units in single-room occupancy (SRO) 
buildings in Brooklyn and Manhattan. This pilot program, based on 
the HF model, enables residents to bypass the bureaucratic hurdles 
necessary to obtain supportive housing. While a start, the 80 units 
represent a paltry 3% of NYC’s empty units. Furthermore, the program 
PZ�ILPUN�Y\U�I`�[OL�UVUWYVÄ[�]VS\U[LLYZ��YH[OLY�[OHU�I`�[OL�JP[ �̀�0M�
the Adams administration truly wanted to solve the issue of housing 
and provide compassionate care for those in need, it might consider 
adopting the evidence-based HF policies citywide in the other 97% of 
reportedly empty apartments.

LANYA SNYDER



18  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

CONCLUSION 

Adams’ MHIR policy takes a page out of the political playbook that 
JVUÅH[LZ�PZZ\LZ�VM�W\ISPJ�ZHML[`�^P[O�[OVZL�VM�TLU[HS�OLHS[O��0M��HZ�[OL�
4/09�KPYLJ[P]L�Z[H[LZ��[OL�VUS`�X\HSPÄJH[PVU�MVY�YLTV]HS�MYVT�W\ISPJ�
areas is that a person cannot meet their basic needs, then perhaps a 
TVYL�JVTWHZZPVUH[L�HUK�LɈLJ[P]L�^H`�[V�ZVS]L�[OL�WYVISLT�H[�OHUK�
would be to pivot from “mental health” and reform current housing 
policies that enable individuals to meet these basic needs. Policing 
unhoused New Yorkers with a SMI and forcibly transporting them 
to overcrowded healthcare systems in NYC do little to reduce the 
intersectional risks for this population. Without reforming policies that 
address long-term care, namely social determinants and housing 
policies, forcibly hospitalizing unhoused New Yorkers in need of 
WZ`JOPH[YPJ�[YLH[TLU[�PZ�UV[�VUS`�PULɈLJ[P]L��I\[�WLYWL[\H[LZ�[OPZ�
cycle. Thus, it is reasonable to conclude that Adams’ MHIR directive is 
largely symbolic—optics for being tough on crime—while doing little to 
implement policy that provides actual relief and support to New Yorkers 
who are unhoused and living with a chronic SMI.

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WSHU�ZH`Z�ZHML�Z\I^H`�WYLYLX\PZP[L�UL^�`VYR�JP[`�Z
��

LANYA SNYDER



20  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

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LANYA SNYDER


