The Case for Forcing the Mentally Ill Into Treatment

Mayor Adams commemorating a program to clear mentally ill and unhoused people off the streets.
Photo: Ed Reed/Mayoral Photography Office

A man, clearly homeless, steps onto a New York subway train. He shakes, sways, and talks to himself, lurching around as the train moves, in the throes of a psychotic disorder. He’s someone in need of help — and for many people, though they’d never admit it publicly, a figure to fear.

The perspective of the American media and the liberal journalists and writers who dominate it is that these fears are wicked, bigoted, even “bourgeois.” Efforts to explore root causes related to mental illness and violence in public spaces are resisted with the insistence that those problems are entirely a product of poverty and need. Attempts to use involuntary treatment to help severely treatment-resistant people with mental illness are decried by the activist class and local nonprofits. The pursuit of safety on the subways in response to fear of random violence, we’re told, “means hiding, quelling, or even outright eliminating certain marginalized populations — Black people, homeless people, mentally ill people, poor people,” as Noah Berlatsky put it. A reporter from the Times of London sniffed, “Almost all the people I meet who are scared of taking the subway are people who don’t use it regularly.” There is an elite message when it comes to danger on the subway: It’s embarrassing to ever be scared.

But fear of violence on the subway is in fact rational, even as we must rise above that fear to embrace compassion. The gloating insistence from progressives that they are never bothered by the behavior of disturbed people on the subway does not fit the facts about mental illness and violence. And if we truly care for those with severe mental illness, we must be willing to understand just how deep their problems go and what must be done to help them and those around them.

Let’s start with problems we don’t have. New York City is not in the middle of a crime wave. There has not been a terrible spike in violent crime in the past year, not in the subways or parks or anywhere else. There was, as in the country writ large, a spike in murders and gun crimes in 2021; the reasons for this are hotly debated, as you’d predict. (I’m going with cops refusing to do their jobs, personally.) Happily for all of us, the pandemic-era crime surge both rose and fell swiftly, and we’re living through a record decline in murders. Subway crime specifically has fallen. New York remains a remarkably safe city for its size by American standards. Whatever our issues with crime, we do need to start from those facts.

So why is there so much fear of crime in general and on the subway in particular? A Sienna poll from July of last year found that large majorities of New Yorkers are deeply concerned with crime, despite the fact that the pandemic crime wave had receded by that point. An MTA poll from this past January found that almost 20 percent of riders would ride more often if not for their fear of violence and crime. New York’s major tabloids have relentlessly beat the drum that the city has become unsafe, and while they would do so even if the crime rate was zero, they’re clearly tapping into a degree of populist angst. Stories detailing the fears of city dwellers are common, and local political officials say that their constituents consistently express fear about street crime. The New York Times felt moved last year to publish a piece investigating this divide between crime rates and perceptions of crime. What gives? Is the public simply irrational?

I would argue that they are not, or if they are, understandably so. There have been a number of tragic incidents lately that naturally have inspired fear, whether that fear is rational or not. In March, a 54-year old man was pushed in front of a subway train in Harlem and killed in a random attack by an assailant with a long history of mental illness; also in March, a man was shot in an altercation on the A train in a random attack by an assailant with a long history of mental illness. This past October, a student was punched in the face, his jaw broken, immediately before a woman was shoved in front of a subway train in midtown; in June 2022, a woman was stalked and followed inside her apartment building before being stabbed to death; in May 2022, a man was shot dead on a Q train; and in January 2022, a woman was killed by being pushed in front of a subway train — all random attacks by assailants with a long history of mental illness. This is the stuff of nightmares, and for each incident like this, there are likely a dozen that are not newsworthy but are nonetheless frightening.

Yes, people with mental illness are, in fact, more likely to commit violent crimes, and the recent liberal pretense that this is not true is a glaring example of our culture’s addiction to wishing away complicated social problems. And social problems do not come much more complicated than the problem of severe mental illness. It is absolutely true that most mentally ill people who use the subway and otherwise occupy public spaces do so without incident. It is also true that a highly disproportionate number of random acts of public violence are committed by the mentally ill. The research tells us so.

A publication drawn from the NIH’s PubMed network and developed by researchers from StatPearls, a health-care education company, lays out the reality plainly. “Certain psychiatric conditions do increase a person’s risk of committing a crime,” the authors write, and “individuals with a severe mental illness that fall through the cracks or for one reason or another and are non-adherent to treatment are particularly at higher risk of committing grave acts of violence.” As has been found again and again in responsible research, “untreated profound mental illness is particularly significant in cases of homicide.” What’s more, the particular conditions of homeless people with severe mental illness in urban spaces make the risks greater; the authors note that “patients with mental illness may be more prone to violence if they do not receive adequate treatment, are actively experiencing delusions, or have long-standing paranoia.”

All of those factors — a lack of treatment, delusions of the type associated with psychotic disorders, and persistent paranoia — are likely to be more common among homeless New Yorkers. Psychotic disorders are vastly more prevalent among the unhoused, and homeless people are more likely to abuse drugs, which dramatically increases the risk of violence. Large literature reviews find conclusively that mental illness is associated with higher levels of criminality. A French review of studies published since 1990 finds that 6 percent of murderers are schizophrenic, which is remarkable considering that less than 0.5 percent of adults have schizophrenia. Relevant to our interests here, 38 people were charged with assaulting MTA employees last year; 20 of them had a history of mental illness, despite the fact that less than a quarter of Americans suffer from mental illness and only one in 20 from severe mental illness.

Obviously, it’s not rational to expect any individual person with a mental illness to be violent. But it is rational to conclude that the severely mentally ill are significantly more dangerous than any random person. Liberal desires to repair the image of the mentally ill, after decades of pop culture that portrays all of them as murderous maniacs, has given way to an assumption of blamelessness. It helps no one, especially not the mentally ill themselves.

Part of the difficulty in getting people to grapple with this reality is the rampant deployment of a strategically deceptive observation — that the mentally ill are more likely to be the victims of violent crime than the perpetrators of violent crime. For example, in a 2021 piece in The Atlantic that argues that more than a half-century of deinstitutionalization did not cause a spike in homelessness among the mentally ill, Alisa Roth writes, “Tough-on-crime rhetoric also helped enforce the persistent assumption that people with mental illness are dangerous and need to be kept off the streets to protect the rest of us … but people with mental illness are far likelier to be victims than perpetrators of violence.” A New York Times piece from November 2023 used the same language, saying “mentally ill people are more likely to be the victim of a violent crime than to commit one.”

That statement is, in fact, true — true and meaningless. It says literally nothing about the question of whether the mentally ill are more likely to commit acts of violence against strangers or not.

The reality is that because a small percentage of people commit the large majority of violent crimes, members of almost any identifiable group are more likely to be the victims of violent crime than to be the perpetrators. We know that men commit a shockingly high percentage of the violent crimes in our society. And using the FBI’s Crime Data Explorer and consulting the National Crime Victimization Survey, we can see that in the past half-decade, men have committed approximately 8.5 crimes per 1,000 while between 16 and 20 men per 1,000 were the victims of a violent crime. We too, as a sex, are more likely to be the victims of violent crimes than the perpetrators, perhaps twice as likely. But would it therefore be sensible to conclude that men are not more likely to be violent than women? Of course not. That’s not what that statistic says, and what it does say is irrelevant.

“They’re more likely to be victims of violence than to commit violence” is meaningless for assessing risk. And yet it’s voiced absolutely constantly — including, I’m afraid, in the PubMed publication I referenced above.

Perhaps the researchers felt they needed to include that tidbit to avoid criticism or accusations of bias, which is another serious dynamic at play here. I’m working on a book about mental illness now, and in a recent conversation with someone who has taken part in coming up with official diagnostic criteria for psychiatric conditions, I was told that few researchers are motivated to investigate relative rates of violence and criminality among those with mental illness. To perform that research is to invite a great deal of invective and accusations of perpetuating “stigma,” for little professional value, so why bother? The lengths psychology researchers go to in order to avoid this fate is remarkable; this study, for example, acknowledges up front that “people with schizophrenia are significantly more likely to be violent than other members of the general population” but goes on to reassure us that “the proportion of violent crime in society attributable to schizophrenia consistently falls below 10 percent.” To repeat myself, the World Health Organization says that the rate of schizophrenia in adults is less than 0.5 percent! How then is the fact that schizophrenics commit less than 10 percent of violent crimes relevant or meaningful in the discussion?

These days, when people can’t argue facts, they argue motive, and it’s inevitable that some will respond to this piece by asking why I’m interested. Why do you care? Who is it serving? I have several answers to that question. The first is that the truth matters; the relative rate of violent crimes committed by the severely mentally ill is an empirical question, and the disability activist community and their enablers in the media have done everything in their power to obscure the truth.

Another reason is that, yes, I am concerned with public safety. This is a deeply uncool thing to care about, but the victims of mentally ill assailants have rights too, and the current rhetorical conditions seem bent on forbidding difficult conversations about how to prevent these incidents. And we have real-world examples of societies that have developed mental-illness policies so lenient that they are a risk to the public. In Toronto, in 2015, a woman named Rohinie Bisesar randomly stabbed 28-year-old Rosemarie Junor to death. She was found not responsible by reason of mental illness was allowed unsupervised excursions into the community by an Ontario review board within a few years, then was released into unsupervised living in 2022. From stabbing someone to death to walking free in less than seven years is, I’m willing say, not an ideal outcome. Call me a fascist for it if you wish.

But the biggest reason I’m opposed to the rampant, reflexive dismissal of violent actions inspired by mental illness is for the good of the mentally ill themselves.

It’s now been more than 60 years since John F. Kennedy signed the Community Mental Health Act of 1963, which spurred the closure of dozens of state psychiatric facilities. In 1955, there were an estimated 559,000 residents in state psychiatric facilities; by 2016, the number of beds in such facilities stood at 35,000. That amounts to, if you’re curious, one bed for more than every 9,000 Americans, meaning that our state psychiatric infrastructure could never possibly accommodate our population of people with mental illness. Of course, there are and have always been those who think that number should be zero because state facilities are “carceral” or similar nonsense. And yet after all these decades of tearing down government-run psychiatric facilities, virtually no one looks at the current scenario of inadequate facilities, overworked doctors, and countless untreated patients and likes what they see.

What’s unclear is why so many people continue to insist that we need even less government intervention and even more hurdles to involuntary treatment. This is a good example of broad ignorance about mental-health policy in this country in the past half-century, even among educated people; I will frequently hear it suggested that we’re taking a more heavy-handed approach to the mentally ill than we used to, when the opposite is true, thanks to policy. Deinstitutionalization shuttered asylums, Medicaid created direct incentives for states to push patients into barely regulated private hospitals, a Supreme Court ruling made the threat of violence a legal standard for involuntary treatment, and the Americans With Disabilities Act dramatically expanded the ability of patients to challenge doctors and hospitals, contributing to a tentative and risk-averse approach to dealing with mental illness.

The current approach to mental-health management, on the societal level, has failed according to just about everyone’s criteria. And yet the broad public conversation continues to be hamstrung by a refusal to contemplate the most essential reform: lowering the bar that the state and medical professionals must clear to treat someone without their consent. The pendulum swung too far.

I was horrified by the vicious killing of Jordan Neely, and I hope that his assailant, Daniel Penny, is convicted in his manslaughter case. But if we care enough for Neely to imagine a world in which he would have survived, then we almost certainly must imagine one in which he was forced into care. Neely simply could not be said to lack for opportunities for care; he was in fact mandated into care by the courts. The trouble was that he was profoundly treatment resistant, a condition that afflicts many of the mentally ill and homeless. I argued last year that involuntary treatment could have saved his life, but the response to that attitude (in my inbox, on Twitter, in activist forums) was ferocious. In a deeply reported and sympathetic history of Neely’s life published in this magazine last December, Dwayne Blizzard, Neely’s mentor, said, “When he got locked up, that could have saved him.” But, as an acquaintance of Neely’s from Rikers Island said in the piece, “We’re killing ourselves to jerry-rig what doesn’t exist because it’s too much of a hot potato to talk about any kind of secure, residential, therapeutic environment.”

As someone who has written about mental illness for years, I’m perpetually amazed at how many people’s first reference for psychiatric treatment is One Flew Over the Cuckoo’s Nest, a 49-year-old movie based on a 62-year-old novel about a man who explicitly does not have mental illness but is lobotomized anyway. Casual anti-psychiatry attitudes are common in the U.S.; The New York Times Magazine, for example, recently published an article casting doubt on conventional treatment for schizophrenia, based on a totally nonrepresentative handful of high-functioning patients who “live with the voices.” Most people who live with the voices do so in a state of poverty and personal chaos, rather than the tranquil life of meditation and music lessons depicted in that article. But resistance to conventional psychiatry, in the American consciousness, is old and durable. This despite the fact that most people who receive treatment for a psychiatric disorder eventually recover.

Anti-psychiatry is abetted by an academic left and activist class that have legitimized anti-psychiatric ideas, under the cover of autonomy and freedom for the mentally ill. The activist class rejects any notion that mental illness induces violence, under typically broken social justice logic; the thinking seems to be that since “the mentally ill” is an identity category (it isn’t) and expressing any negative feelings towards an identity category is bigoted, to say something negative about the mentally ill (such as that they have a higher propensity to violence) is therefore forbidden.

They also, in general, rigidly resist involuntary treatment, despite the fact that psychotic disorders prevent those who suffer from them from making rational and free choices. Following Neely’s death, the Alliance for Rights and Recovery demanded “sweeping reforms” but insisted that any engagement with the mentally ill be strictly voluntary. As such groups always do, it also called for greater resources for mental-health care, which we do in fact need. But voluntary care and more resources could not have saved Neely’s life, as he simply walked away from treatment he already had access to. And this is indicative of the poverty of the activist class on this issue: Because so many major nonprofits and activist groups have forsworn compulsory treatment, they’re incapable of confronting a problem like Neely’s.

This piece from the Guardian is typical of the liberal response: The author laments that Neely would have faced “stacked odds” in finding care. But Neely was already in care! He was in care several times in his life! Finding care was not his problem. His problem was his refusal to stay in care.

To point out a tendency among the mentally ill to commit violent acts is to contribute to “stigma,” the greatest enemy of disability activism and, for most suffering with severe mental illness, rather besides the point. As in so many other domains, it is not in fact the case that the mentally ill need a witless and blank positivity from the rest of us. They need help, and what they specifically need help with is overcoming the way their illness prevents them from seeking care.

To really love the severely mentally ill, you must be willing to accept all of what they are. In Jordan Neely’s case, that included being erratic and unstable as well as creative and bright, a habitual consumer of dangerous synthetic marijuana as well as a born performer, and a man whose mental illness contributed to a habit of committing random acts of violence. And, crucially, he had been given the opportunity to avoid prison through exactly the kind of diversionary program that liberals and leftists have been demanding for years, and he simply violated the terms of that program because he was too sick to make a better choice.

This will, inevitably, be represented as me blaming Neely for his own death, when in fact I am certain that Daniel Penny deserves all of that blame. I am, instead, willing to acknowledge that Neely had a chance to escape his sad life into a better one but was too overcome with instability to do so. Some people need to be forced into treatment to save their lives.

In his brilliant, mournful book from last year, The Best Minds, author Jonathan Rosen details the story of his childhood friend, Michael Laudor. Laudor was a brilliant young man who had a psychiatric crisis while in his early 20s and was diagnosed with schizophrenia. After a long hospitalization, he was able to persevere and graduated from Yale Law School. His story was so inspiring that he became a kind of cult celebrity, was the subject of a beaming New York Times profile, and sold the rights to his story to both a publishing house and to Hollywood for millions of dollars. For many, he served as a powerful positive symbol of what the mentally ill could do — right up until the day he hacked his pregnant fiancée to death with a kitchen knife. And what Rosen reveals, detail by meticulous detail, is how the many people in Laudor’s life who thought they were doing him a favor by “accepting” him were in fact enabling him and, in so doing, acting as handmaidens to his undoing and his fiancée’s tragic death. He has spent every day of the 21st century in a maximum-security psychiatric facility.

What if I told you that he might be living a full and functioning life, married to the woman he killed, maybe working as a lawyer, if our system had found the courage to say, “You are going into treatment, and you cannot say ‘no’”? And what if I told you that, whatever we choose to do with Jordan Neely’s killer, Neely might have been saved if, before his death, we had mustered the integrity to look at the full horror of mental illness and actually, really committed to doing something about it?

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