The Last Time NYC Tried to Hospitalize the Homeless
Speaker 1: Good morning, New York City.
Mary Harris: A couple of weeks back, the mayor of New York City had this press conference that’s been reverberating ever since. It was about a problem a lot of urban leaders are facing right now, homelessness.
Speaker 1: We see them every day and our city workers are familiar with their stories.
Mary Harris: The number of homeless New Yorkers is about as high as it’s ever been. Winter is setting in, and Eric Adams, a police officer turned politician, is clearly feeling the need to do something.
Speaker 1: They cycled in and out of hospitals and jails. But New Yorkers rightly expect our city to help them and help them. We will.
Mary Harris: The help the mayor proposed involuntary confinement. This did not go over very well.
Speaker 3: Mayor Eric Adams has been facing the heat over his new directive, which forces homeless individuals suffering from severe mental illness into a hospital for evaluation without their consent if needed. So he doubled down on Monday.
Speaker 1: I didn’t get elected to do easy task.
Mary Harris: 3000 miles away. Sam Tsemberis was watching all this play out with a distinct sense of deja vu.
Sam: It was a very, very, very sad moment for me because this was not an announcement that I’ve heard for the first time in my career. You know.
Mary Harris: Sam advocates for the homeless. He used to work for the city of New York. Actually.
Sam: The thing that was most discouraging is that we’ve done this before and we learned a great deal from what works and what doesn’t. And when I heard this announcement, it’s like we’re going back 40 years. We were like literally turning the clock back as if we had learned nothing in these 40 years.
Speaker 3: Well, estimates of the homeless vary. Some say there are as many as 60,000 homeless people in New York City.
Mary Harris: This is what it sounded like back when Sam was working in New York. Ed Koch was the mayor. And like the current administration, Kotch thought getting people off the streets was in everyone’s best interest.
Speaker 3: In November, New York’s mayor Ed Koch announced a new policy regarding the homeless. The temperature drops to 32 degrees or below. City officials declare a cold weather emergency. Police go into the streets and ask the homeless to go to shelters. If they refuse, they can be taken involuntarily to city mental hospitals for a psychiatric evaluation.
Sam: Ed Koch announced an involuntary hospitalization program for New York City when someone had frozen to death was an elderly woman living in a cardboard refrigerator box. You know, those large boxes that the refrigerators come in that had been discarded on the street somewhere in the Wall Street area. She was using it as a home. She was in the box at night. And then the temperature dropped overnight. And then people came back to work on on Monday morning and found her. You know, she had passed away.
Sam: And that created a tremendous public outcry, Koch said. I don’t want anyone dying on the streets of the city. We believe that anyone who chooses to be out on the streets in freezing weather when offered the opportunity to have a shelter, we believe that that person is not competent to make such a decision.
Mary Harris: Sam was eventually put in charge of administering this program, but he resigned in frustration, not because the people he worked with weren’t well-intentioned. He just didn’t think forcing people into hospitals was working. Watching the current mayor announce this new plan, Sam could hear him justifying his decision the same way Ed Koch did back in the eighties.
Speaker 1: No more passing the buck. Going forward, we will focus on action, care and compassion.
Sam: I think it’s positioning. I think we’ve always had the moral responsibility to take care of people. It’s like the problem is that his suggestion, where he takes that very good instinct of owning the problem and feeling it, it’s a moral responsibility. Where he takes it to is involuntary commitment, which is a misguided intervention. We have a moral obligation, but the moral obligation is to get people off the street and get them safe and get them well. Involuntary treatment for a short stay in the hospital accomplishes none of that.
Mary Harris: Today on the show, understanding New York’s new approach to helping the homeless, which actually is not very new at all. I’m Mary Harris. You’re listening to what next? Stick around.
Mary Harris: Sam Tsemberis first began to understand the way a homeless policy works in New York. From the ground level, it was 1985 and the mayor had just announced that new program, the one that would involuntarily hospitalize people living on the street. Sam was the guy taking those people in.
Sam: I got involved right in the beginning, right at the beginning of this problem. I was trained as a psychologist. You know, I went to NYU. I was working at Bellevue Psychiatric Hospital. I was living in the East Village. And walking to work, you know, from Third Street to 30th Street. I started running into people on the street that I had seen on the inpatient service.
Mary Harris: What did you do? Do you say hello?
Sam: Well, of course. Isn’t I like, you know, like Frank, what happened to you? Like, how are you here as as well, you know, I was that they wanted to discharge me. I told them, yes, I have a place to stay. You know, my aunt’s house because I wanted to get out of there. You know, it’s very restrictive being in the hospital and kept jabbing me with needles for the medication. You know, I wanted out. So. So here I am.
Mary Harris: It was this revolving door aspect of the city’s approach that bothered Sam the most. The hospital could only keep folks a few weeks at a time, and homeless people themselves wanted to get out as quickly as possible. It seemed like no one was looking to solve anything permanently. There was also the issue of civil rights. A couple of years into Mayor catches Involuntary commitment program, it got challenged in court. By then, the program was better known as Project Help.
Speaker 3: The first to be picked up and challenge conscious program was 40 year old Joyce Brown, a former secretary from New Jersey.
Mary Harris: Joyce Brown, who called herself Billy Boggs, was a black woman who refused psychiatric medication and was forcibly hospitalized. The New York Civil Liberties Union argued refusing treatment Was Billy Boggs, right?
Speaker 3: The city claimed she was schizophrenic and had defecated in the streets. She said she was a professional homeless person who had lived for the past year on Second Avenue, next to a hot vent on the side of an ice cream parlor.
Speaker 1: The question is not whether she’s eccentric. It’s whether she’s.
Sam: Dangerous to herself. And this woman clearly is not dangerous to herself. And what happened with Billy Boggs is that she would also panhandle, you know, when the when the cars would stop at the red light, she would get up and and she would ask people for money, you know, as they waited for the light to change.
Mary Harris: She would also yell at folks to ride and try to keep them away from her with an umbrella.
Sam: Yeah. Yeah. She she didn’t like people throwing money at her. She felt that was very disrespectful. She yelled at them if they were if they made comments about her. She also got into a lot of arguments with the people that ran the restaurant because she’d have to use the restroom and they would say it’s for customers only, you know, And she she would argue that she had bought a coffee there. And she was a very, very visible and very verbal person, you know. And so when the hospital called the Project Help team, I read the write up of what they said. They said, you know, this woman was aggressive. They said that she didn’t have any judgment because she would wander into traffic and present a danger to herself because, no, she could possibly be hit by cars and she wasn’t aware of that.
Mary Harris: Do you agree with that assessment?
Sam: You don’t want to see anybody living like that. But it wasn’t exactly she was a danger to herself or to others, any more than any of us would be if we were homeless and had to live on the street.
Mary Harris: So what happened after she was involuntarily detained?
Sam: They took her to Bellevue on an involuntary commitment and they were able to actually get her hospitalized because at that time, a special unit had been set aside at Bellevue Hospital just for project help, because I don’t think she would have made it past the psychiatrist in the emergency room otherwise. And then they wanted to force her to take medication. So she refused the medication. And I believe that’s when the ACLU got involved and the case went to the there’s a court right at Bellevue Hospital to adjudicate these cases. And the she won her case not to be medicated. And so the hospital then discharged her, saying that, well, if we can’t medicate you, you know, what can we do for you? We can’t do anything for you. So she was discharged back out of the hospital.
Mary Harris: After she was released. Billy Boggs became famous for resisting project help. She spoke at Harvard, went on talk shows, and when she spoke to one local news anchor in New York, he even claimed he knew her.
Sam: No, but I’m telling you, back then, you were a mess. You were in big trouble. And I’m betting that if the city didn’t didn’t do what they did for you, that you might have been dead by now. You might have frozen to death.
Speaker 3: No, I would not be totally incapable of. I had found a hot ear vein in which I was warm. I was better off than some people were in apartments with no heat, and I would not have been dead. I was not in any medical bad condition. When I arrived at the hospital. I was in good health.
Sam: And it created a tremendous press coverage about people’s rights and the usefulness of this program. But you’re better.
Speaker 3: Off than you were three months ago. I didn’t receive any care while I was. You got a.
Sam: Better person than you were three.
Speaker 3: Months ago. The same person that I was three months ago.
Sam: You look a lot better to me.
Speaker 3: Why? Because I have a clean sweater now. Because that makes my mind that you’re.
Sam: Making sense.
Speaker 3: For me.
Sam: And I think the general consensus was that she didn’t really meet the criteria for danger to self or others. And I think that’s why the program was looking for a new director. And that’s when I got the job.
Mary Harris: Even though Sam wasn’t sure that forcing homeless into the hospital was a good idea, he agreed to lead the mayor’s program anyway. There was a part of him that hoped he’d be able to change things from the inside.
Sam: You know, I applied for the job and I said, Yeah, I want to help people who are homeless and have mental illness, but I don’t actually believe in involuntary hospitalization. And they said, What do you mean? You know, you know what this program does? So I was very cautious about who we would bring into the hospital or who I thought would meet criteria.
Mary Harris: Did you ever have to involuntarily hospitalized someone and really think about it and struggle with it a bit?
Sam: Oh, I don’t think there was ever one time where we didn’t struggle with it. I think it was easier for me. When there was a medical problem. You know, if somebody has like there you see that they’ve been hit over their head, they have a swelling next to their eye, their eyes closed and black and blue, and they haven’t taken care. You don’t know if they’re internally bleeding or they you know, what’s going on with them.
Sam: In those situations, when there’s a medical complexity that was like that was not at all a problem of, you know, ethical dilemma. For me, it’s like this person has to go to the hospital, you know, like we have to at least know that they’re medically okay. When people, you know, were symptomatic, you know, didn’t really have a plan of how they were going to take care of themselves. Those were much, much more difficult because it was hard to make the decision that you knew better than they did. Like, what is the best thing for them?
Mary Harris: So explain to me how you knew that the push to involuntarily hospitalized people really wasn’t working.
Sam: You know, the way I learned that it wasn’t working clinically was because after we took the trouble to bring someone to the hospital, 30 days later, they would be back out on the street, you know, often with the same little plastic shopping bag with their stuff that they had when they went into the hospital. It’s like, oh, what happened here? The hospitalization was taking care of, you know, the person’s immediate problem, but they weren’t doing anything in terms of addressing their homelessness. There was no housing program attached to the hospital. And there still isn’t to this day.
Mary Harris: When we come back, what happened when Sam tried to build this housing program from the ground up?
Mary Harris: In the end, Sam Tsemberis only spent four years at New York’s Project Help. Pretty soon he was working on his own project, a solution he thought would be more long term for homelessness. The idea was simple to just give homeless people places to live, even if they had mental health issues or drug problems.
Sam: So we started we started this Pathways to Housing Organization, you know, as a nonprofit and got a grant from the state Office of Mental Health for what’s called supported housing. So we had money to pay people’s rent, and we had money to hire case managers to look after people once they’re housed.
Mary Harris: And how did you choose who would get housing?
Sam: Well, we’re basically choosing the same people we were talking to when we were doing street outreach. You know, the very same people that we had considered hospitalizing before. We were now saying, hey, how about this? How about a place to live, you know? And they would say, Are you kidding me? Is that like on the level? Yeah. Really? Yes. You don’t have to take medication. You don’t have to be clean and sober. You can come right as you are with your shopping bags. And we’ll we’ll help you find a place and you can move in.
Mary Harris: I mean, I know you’ve said you didn’t kick people out of their their homes even when they really messed up, like sold all their furniture to buy drugs. So what does. Treatment and accountability look like for a person in that situation.
Sam: It looks like the same as it does for all of us. I mean, people had to sign a lease, right? And they had to meet the terms and conditions of a standard lease. Now, most people manage that. Okay. But but some people did. You know, some people when they moved in, had people that they knew on the street and they couldn’t turn them away. You know, they couldn’t turn their friends away and let them be sleeping on the sidewalk when they had this apartment that had it was warm and safe. So some people got evicted and not a lot, but, you know, 20%, you know, and it’s like at that point, we had a dilemma about what to do. You know, the easiest thing to do would have been to say, okay, we gave them a chance. You know, they messed up and, you know, they’re back on the street. It’s on them. But we didn’t we didn’t say that.
Mary Harris: Did you rehouse them?
Sam: Oh, of course we refused them. If they wanted to be rehoused. We rehouse them. We rehouse them with the understanding that we had learned something from the last eviction.
Mary Harris: So when you looked at the effectiveness of your program after doing it for a few years, what did you find?
Sam: Well, this is the amazing thing, Mary. I mean, I had looked at the data for housing effectiveness in New York City, housing programs that were being operated in the traditional way, which means in order to get housing, the typical approach is you have to be clean and sober. You have to be stabilized on psychiatric medication. So you have to have your treatment piece totally together before you get housing.
Mary Harris: It’s a reward for the good little boys and girls.
Sam: Exactly. Exactly. And there have been, by the way, today. Today, in 2020, the Center for Disease Control published a paper that talks about 26 studies of housing first compared to treatment as usual. And all of them have more or less the same results, which is that people who are homeless and have mental health issues and addiction issues that go into housing first programs are stable housing typically 80 to 90% of the time, compared to 30 or 40% when you have to do the treatment and then housing.
Mary Harris: Can we look at New York as an example? Because I think New York’s a really interesting example with a lot of progressive people in government who have embraced the idea of supportive housing, the kind of housing you’ve found to be very beneficial for chronically homeless people. So let’s talk about why in New York City, despite this commitment to helping people get off the streets, it doesn’t seem like. Housing First is delivering on its promise. Like, what are the things that are getting in the way?
Sam: What’s getting in the way is that we don’t still don’t have a national health policy where it’s easy to get access to care. And we’re not building any housing that’s affordable for this group of people. So people are saying, well, you know, if housing first works and it solves homelessness, why do we still have homelessness? Well, that’s the same thing as saying, well, if hospitals work and they cure illness, you know, why do we still have sick people? You know, it’s like, you know, we have to take it to scale, but we don’t agree. We don’t agree as a country, how to take it to scale. People are still doing lots of shelters. There’s a lot of shelters being built under the last administration. You know, there were expanding shelter capacity. We’re not focused on one approach and staying with it.
Mary Harris: We’re doing everything all at once.
Sam: We’re doing everything. And so you get a little bit of a scatter shot, a little bit of this, a little bit of that. If you look at if you look at communities that have done really well in reducing homelessness recently, for example, Houston has gotten a lot of attention. They have reduced homelessness by 63%. Okay. Well, how did they do it? They committed more than eight years ago to a housing first approach. They were all about getting housing people into housing, not the shelters. Housing and services. They continued that same approach over to mayoral administrations. So there was continuity of purpose and philosophy and funding.
Mary Harris: I was really struck by the fact that last month The New York Times reported there were 2600 vacant supportive housing units in the city, which is massive, given that, you know, about a year ago, 3400 people were living on the street. So when you have 2600 vacant sort of housing units, that’s could make a major dent in that.
Sam: It could. And I think that one of the reasons that they’re vacant is because people are still holding on to the old treatment and housing philosophy. And so while they’re waiting for people on the street to get well, to get sober, to participate in treatment, which is very, very hard to do because when you’re on the street, all you’re thinking about is survival from hour to hour, literally, You know, you can’t think about anything else. So we have these empty units because the demand criteria for getting into them is unattainable to meet for people who are homeless.
Mary Harris: Yeah, people have talked about the application process being incredibly onerous and you have to go through many mental health screens.
Mary Harris: All sorts of things. And then landlords can say, No, you seem too complicated and all of that. It seems. Kind of anathema to what you envisioned at the beginning, which is just, Yep, you get a home, you get a home, you get a home. We’ll figure out the rest later.
Sam: That’s right.
Mary Harris: And I think the Times said only 16 people who got supportive housing in the last year had come from the streets. So only a few people had been in the kind of diarist situation there could be.
Sam: Right. Because people are not going to accept tenants coming in off the street that don’t look like they’re going to make it in housing. It’s one of those totally illusory things, by the way, because people see with their eyes someone that looks in very bad shape on the street and they can’t imagine this person living in an apartment. And I can tell you from my own experience, hundreds and hundreds and hundreds of times over again, you take that person and you put them right into an apartment and they give them some clothes, you know. And a couple of nights rest. And like the very next day, they’re coming out of that apartment with their key in their hand, and they’re virtually indistinguishable from any other tenant in the building.
Mary Harris: What would you say to a New Yorker who’s scared? Because when Eric Adams, the current mayor, took office, it was in the middle of. I don’t want to say a crime wave. I just want to say a lot of fear in the city. There had been attacks in the subway on folks. And I felt like it just made a lot of people who lived in the city think. I want this fear inside me to go away. And that’s part of what the mayor’s responding to here.
Mary Harris: What would you say to someone who feels like that?
Sam: I would say, you know, that this fear is totally understandable and we shouldn’t any of us have to experience it. And the solution for managing this fear long term, not in some Band-Aid and kind of dramatic way, is to house everyone who needs housing. We should not have homelessness in this country. We have the resources to end it. You know, none of us should have to live in a city where we feel afraid. I think it will be much healthier for people experiencing homelessness and certainly much healthier for the rest of us.
Mary Harris: Here’s a question I’ve been asking myself. Is there any way a plan like the one Mayor Adams is talking about could work? If a homeless person was hospitalized. But as part of that, there was a very direct hospital, the housing pipeline. Is that something where you’d say, okay, we’re moving in a better direction?
Sam: If there was a hospital, the housing pipeline, we can put them directly from the street into housing, save them the hardship of going to the hospital, the expense of the hospital stay and going right in. We just need to bring the person right to housing. You don’t need involuntary commitment to housing. In fact, if you offered housing, people would go voluntarily, willingly, happily.
Mary Harris: So you’re saying the problem is there from the start, or is it just saying we’re going to be in voluntarily committing people? You’re setting yourself up to fail?
Sam: Totally. You know, I mean, if there was a robust housing program attached to a hospital, we could just skip the hospital altogether and go right to housing. So the hospitalization, the involuntary commitment is really politics. You know, it’s like trying to assure the public that the mayor is doing something about it, which, look, it’s good that they’re thinking about doing something, but we could be doing something so much more effective. You know, I mean, maybe we could turn this moment of all this attention and controversy into something positive by at least proposing a solution that will work long term as opposed to placating short term.
Mary Harris: Sam, thank you so much for taking the time to talk to me. I’m really grateful.
Sam: That was great talking to you, Mary. Thanks for inviting me.
Mary Harris: Sam Tsemberis is a clinical community psychologist at UCLA. He’s also the founder and CEO of the Pathways Housing First Institute. And that’s the show, if you’re a fan of what next? The best way to support our work is to join our membership program. It’s known as Slate Plus. The way to do it is to go on over to Slate.com, search what next plus and sign up right now. What next is produced by Elena Schwartz, Carmel Delshad, and Madeline Ducharme. We are getting a ton of support right now from Anna Phillips, Jared Downing, Sam Kim and Victoria Dominguez. We are led by Alicia montgomery and Joanne Levine. And I’m Mary Harris. I’ll be back in the studio bright and early tomorrow. Catch you then.