Mental Health System Reform in New York City
After extensive research on the current state of mental health care services in New York City, we propose a number of strategies to improve the efficacy and accessibility of treatment options. Outlined below, these initiatives are intended to work in conjunction with existing programs and resources with the hope of conserving funds and increasing the plausibility of implementation.
A. Build Social Support
For any initiative to get off the ground and be widely accepted, social support for its goals must be built. While stigma surrounding mental illness and its treatment has lessened somewhat, many people remain uneducated, hostile, and reluctant to interact with mentally ill populations. Public awareness campaigns and mental health first aid training will play a role in addressing these concerns.
B. Improve Transparency of ThriveNYC
ThriveNYC, a citywide initiative launched in November 2015 by First Lady Chirlane McCray, has been key to addressing a number of mental health care gaps. ThriveNYC lays out a roadmap for the future of mental health care, with an eye toward continued expansion of its programs until the goals are met. Programs aim to change cultural awareness of mental health, implement early intervention programs, make mental health care accessible and affordable, and integrate political awareness and activism into the current health care infrastructure. However, although progress updates are readily available, there is a concerning lack of data on program efficacy and validity. Measures of accountability must be implemented to ensure the success and continued thriving of ThriveNYC.
C. Improve Community-Based Care
With deinstitutionalization came a spike in underserved mentally ill populations,primarily those who are homeless, incarcerated, or simply do not have the financial stability to support their own treatment. We propose increasing the number and efficacy of community-based treatment centers to make mental health care more accessible, affordable, and comfortable. Many community members are more likely to trust the expertise of professionals who share a common background with them; similar cultural, religious, and socioeconomic backgrounds foster open communication and trust.
D. Integrate Medical and Psychiatric Teams
Currently, there is a lack of communication between medical and psychiatric professionals, many typically working in separate clinics or wards within a hospital. We suggest integrating teams, joining forces to address all aspects of a patient’s health concerns more holistically. Paying closer attention to the state of health care teams also involves addressing burnout or compassion fatigue, in these cases. Failing to do so risks having apathetic health care workers; both the provider and the patient suffer.
Background on Mental Health Care in NYC
New York City’s mental health care system has drastically improved since the 1950s, but continues to be riddled with problems. The main issues in the system include stigma against the population with mental illness, lack of testable program results, the intersection with other at-risk traits for the population with mental illness, and poor communication among health care providers. To create tangible solutions, we must identify the historical and contemporary context of these issues before moving forward.
A. Stigma
Stigma is the pervasive negative attitude by which society views the population with mental illness, but also 
encompasses the negative attitude with which the population with mental illness views mental health care treatment. Within the past five decades, society’s view of the mentally ill has gotten better on a superficial level. Although public opinion on treating mental illness is more upbeat than it once was, people still have issues with interacting with people with mental illness on a personal level.[i] On the other side of the issue, we see a mistrust of the mental health care system from the perspective of mentally ill patients because of unnecessary treatments from health care providers, culturally or ethnically insensitive provider attitudes, and high treatment costs.[ii] Especially among Asian populations, seeking help for mental illness outside of friends and family is widely considered taboo.[iii] As such, social stigma from both parties must be erased for improvement in the mental health system to be lasting and effective – which leads into the next major problem within the system: quantifiable results.
B. Unmonitored Mental Health Programs
Deviating from mental health care in the ’60s, public policy for mental health has changed such that power has been taken away from state mental health authorities and given to mainstream programs and providers.[iv] Mainstreaming provides the mentally ill population with autonomy and a greater variety treatment options, but results in a fragmented maze of mental health programs that can be difficult to navigate at best and cause serious trauma to people with serious mental health problems at worst.[v] These mental health programs need to develop cohesion, but also prove that their treatment methods are effective by reporting regularly to the public and other authorities. Many of these programs fail to follow their original goals or maintain their standard of care over time, contributing to greater suspicion of the mental health system from the public and populations with mental illness. All mental health care initiatives must be held accountable through reports and other quality assurance means, including the mayo
r’s recently launched ThriveNYC.
C. Intersectional At-Risk Population with Mental Illness
Deinstitutionalization began in 1955, reflecting the general public’s aversion to state mental asylums as inhumane warehouses for mentally ill populations. In response, thousands of patients with chronic mental illness were released from overcrowded state hospitals into city streets, where many have stayed.[vi] Instead of receiving more human treatment from the community, these released patients have experienced what some ethicists call “transinstitutionalization” – they have shifted into medical hospitals, nursing homes, and prisons. These facilities are even less well-equipped to deal with the intricacies of the population with mental illness, especially with the level of specificity required for serious mental health conditions.[vii]
Deinstitutionalization may have fostered the intersecting problems the current population with mental illness suffers: poor education, underemployment, self-harm, incarceration, and substance abuse.[viii] The incarcerated mentally ill are particularly difficult to help due to incompetency and the stigma prison staff attach to them. Racial bias can also be a further barrier. In a study of jail admissions in New York City, staff were more likely to respond to bad behavior by Caucasian inmates as a reason for treatment, while they viewed bad behavior by young blacks and Hispanics as reason for punishment. As a result, blacks and Hispanics were given more “derogatory” mental illness labels as well, such as antisocial personality disorder as opposed to depression.[ix] This overlap of incarceration, age, race, and stigma show that New York City must take a more cohesive approach in future mental health care strategies and community-based care.
D. Fragmented Communication between Providers
To tackle a complex population with overlapping mental illness conditions, health care professionals need to provide a united network of care. Several agencies and providers deal with the population with mental illness, including the Department of Correction, the Department of Health & Mental Hygiene, state agencies, various hospital organizations, and community centers. Unfortunately, poor communication among different agencies plagues the health care system.[x] Since employees in each department or organization view themselves as separate entities from other provider groups, there is lack of understanding regarding the legal responsibilities and action plans of other departments and organizations.[xi] As a result of this division, different treatment programs catering to the same mental health care conditions offer redundant care or inconsistent rules to their already suffering consumers, augmented by the changing Medicaid, Medicare, Social Security, and private insurance policies regarding the coverage of this care.[xii]
Even focusing on the narrower medical and psychiatric scale of the health care system, a primary care physician and a behavioral health care provider for the same patient may never interact with one another. This lack of communication is alarming because not only does it reduce the physical quality of treatment, as psychiatric drugs can most definitely affect physical health and vice-versa for medical drugs, it also causes a sense of impersonal care to the patient.[xiii] Before New York City begins to address the issues of its population with mental illness, there must be cohesive and coherent interagency and healthcare networks in place.
Supporting Points for Proposed Solutions
A. Building Social Support
Research has shown that the knowledge of mental health first aid allows people to recognize behavioral health challenges better, increase people’s confidence in their ability to help (which can lead to an increased amount of help given), and most importantly for New York City, decrease stigmatizing attitudes toward mental illness.[xiv] The last point should promote better societal inclusion of people facing mental health problems.
More money should be allocated into these mental health first aid programs initiated by Thrive NYC because there are different courses of instruction offered based on the situations different people face. These courses help people who have friends or loved ones dealing with mental health issues to be able to build the best support system for them. The different certification programs include adult, youth, public safety, veterans and military families, higher education, and older adults. Adult mental health first aid is for adults over 18 years who want to learn how to help people struggling with a mental illness and includes a five-step action plan to support someone developing signs and symptoms of a mental illness. Youth mental health first aid is designed for adults who regularly are around young adults and teach them how to help a younger age group deal with crisis situations. Public safety certification is for adults in law enforcement and public safety because individuals experiencing mental illness and substance use disorders are more likely to have some contact with the
criminal justice system than the general population. Therefore, this course better prepares officers and staff to respond effectively and appropriately to these individuals. Certification for veterans and military families is designed to teach people how to help a veteran who may be experiencing a mental health related crisis or problem. This is especially important for families of veterans because they often are not aware of how to engage veterans with mental illnesses and addictions. Higher education certification courses teach how to help college students learn to help each other in their unique culture and resources. Lastly, the mental health first aid for older adults is different from the others because mental illness and aging can be considered a double stigma. This is an important course because older adults are less likely to identify a problem as a symptom of a mental health disorder. They have high rates of late onset mental health disorders and low rates of identification and treatment.
Another way the culture around mental health can continue to change for the better can be through an emphasis on ThriveNYC’s formation of the Mental Health Council to promote and implement mental health prevention and treatment programs across New York City agencies.[xv] The council will serve as an advisory group to the mayor on initiatives that promote mental wellbeing and increase access to high quality mental health care by working with public and private organizations. It would also make recommendations to the mayor of legislative actions that can be taken to improve the lives of people suffering from mental illnesses. Members of the council consist of representatives of mayoral agencies including the Department of Health and Mental Hygiene, the Administration for Children’s Services, the Police Department, Fire Department, the Mayor’s Office of Criminal Justice, and the Department for the Aging. Hopefully these representatives will help eliminate the challenges too many New Yorkers face when trying to receive access to mental health care and treatment.
B. Improve Transparency of ThriveNYC
ThriveNYC, as noted above, has implemented a wide range of programs addressing mental health treatment gaps and attitudes. Initiatives range from public awareness campaigns to mental health first aid training, even taking into account the needs and circumstances of various demographics. With its budget of $850 million over four years, ThriveNYC must be held accountable for accomplishing what it purports to do and subject to thorough review by mental health care professionals. Simply implementing a program is only the beginning of change; there must be room for feedback-based adjustments to ensure proper use of funds. Other decentralized quality assurance agencies can also aid the city efforts by providing greater incentive for health care professionals to give regular feedback and structured data. To clarify, companies that do not act on behalf of ThriveNYC would be able to offer unbiased data analyses on the programs and on the data analysis carried out by ThriveNYC itself. With outside forces working to ensure efficiency of programs, ThriveNYC administrators will be under pressure to maintain acceptable standards and progress.
Fortunately, ThriveNYC does have some measures in place to provide feedback about program efficiency. Teams work with data collection and analysis, assessing whether participants are benefiting from services and whether funds are being properly funneled into programs. A report issued on ThriveNYC’s progress during its first year[xvi], 2015-2016, detailed the inner workings of these data programs, naming survey administration as one collection method. Oddly, the first year report doesn’t address the actual implementation other than data services they provide. It doesn’t say whether any tweaks have been put into place due to these data services or whether the resources poured into these services are worth it. We propose a higher level of accountability, namely carrying out a meta-analysis on the data collection effectiveness itself. With $850 million at stake, administrators must be certain that their programs are worth continued funding and resources.
C. Improve Community-Based Care
The most efficient way to run mental health facilities is to have community-based mental health services so that not only will mental health patients be treated, but they will slowly be integrated into society so they won’t relapse. This will enable them to live outside the mental health facility and get a job in the outside world. The main goal for mental health systems is to not make their facilities so inclusive that the “outside” world looks threatening to return to.
One exemplary health system that seemed to incorporate many of the aforementioned characteristics of an ideal mental health system is the one in Trieste, Italy. Deinstitutionalization occurred in 1978 when psychiatrist Franco Basaglia persuaded Italy’s parliament to pass a law requiring the closure of all specialized mental hospitals in the country.[xvii] The previous model was replaced by one with an emphasis on interpersonal relations and improved living conditions. It encouraged societal integration. Community centers are set up as access points and act as the planning, caring, and social arm of the mental health system. Therapeutic, social, and rehabilitative services are continually provided. The club-like atmosphere of the center is so normalizing that it hard to distinguish staff from the patients from the family and friends who are welcomed to visit the patients. There are many group activities with staff, volunteers, and family that promote a social network of friends and colleagues, which play an important role in the therapeutic process of social reintegration. There is also family involvement in treatment planning as the professionals continually work with families to discuss any recurring problems, simulate possible changes, and to build the alliance with the therapeutic program.
The largest public-private partnership with ThriveNYC is Connections to Care. Fifteen community-based organizations were selected to receive grants to partner with mental health providers, get training for their staffs and improve access to mental health care in their communities through the Connections to Care program.[xviii] The organizations would provide services that range from daycare for children with parents who suffer mental illnesses to workforce development for helping people integrate themselves into society better. Their geographic reach spans all five boroughs, making them accessible. Social service staff at all 15 community-based organizations receive training from their mental health provider partner to offer non-clinical mental health support to clients in three target populations: expecting parents and parents with young children, young adults who are out of school or out of work, and unemployed or underemployed adults over 18. Connections to Care aims to help the participants improve their mental health and their successes with other social services provided by the community-based organization.
Opening more community centers like Connections to Care will not only create more of an emphasis on community-based care, but will also broaden community acceptance of mental health issues.
D. Integrate Medical and Psychiatric Terms
When mental health care professionals help care for people dealing with mental health care issues, they often burn out and become apathetic workers. There should be teams of individuals who work together to help mentally ill patients, thus sharing the emotional load.
When author Norah Vincent admitted herself into a public mental health hospital, she faced apathetic and neglectful staff with miniscule amenities. For example, she was in the emergency room sleeping in the hallway because there weren’t enough gurneys available. When she tried to sleep, the night staff was inconsiderate and socializing in their stations. In the patient’s perspective, Vincent said, “We were invisible, discounted, like baggage or the dead, stowed and impervious. We could tell no stories, the assumption being, I expect, that we were all too drugged or nuts to notice or lodge a complaint.”[xix] They talked to patients like they were retarded or elderly that could no longer be helped. Whenever a patient had a request, they would begrudgingly help out and only did their jobs out of necessity, not because they actually wanted to be there.
A way to split up the work and to fix the problem of fragmented communication between different services, we can create multidisciplinary teams of health care professionals that share the workload and all work together to treat patients. A model that can be used for their broad spectrum of professionals in their mental health systems is the Dutch FACT model, which is known as Flexible Assertive Community Treatment.[xx] The model uses diversified teams of around a dozen people, including psychiatrists, psychologists, nurses, substance-abuse specialists, individual employment placement service workers and peer counsellors. These professionals give individualized and time-unlimited services to those with mental illness who are most unstable. The other people with mental illnesses receive case management coordinated by a manager from the same diversified team. The manager draws on the expertise of all team members to provide multi-disciplinary care that focuses on recovery and rehabilitation.
Conclusion
After extensive research on the current state of mental health care services in New York City, we propose these strategies to improve the efficacy and accessibility of mental health care. These initiatives are intended to work with existing programs and resources to conserve funds and increase likelihood of implementation. Looking toward the future of New York City’s mental health care services, our suggestions include building social support, regulating transparency of ThriveNYC, improving community-based care, and integrating medical and psychiatric teams. The models we have built draw inspiration from existing programs known to be successful in rehabilitation and relapse prevention. We focus primarily on building support from the ground up within communities, creating an atmosphere of trust and support sustained by both medical and psychiatric professionals. In addition to integrating our own suggestions within the current mental health care infrastructure, we aim to hold our city’s government accountable for the efficacy of programs implemented through ThriveNYC to ensure proper use of budget.
Endnotes
[i] Richard G. Frank and Sherry A. Glied, Better But Not Well: Mental Health Policy in the United States since 1950 (Baltimore: Johns Hopkins University Press, 2008), chap. 7.
[ii] Michelle R. Munson et al., “Cornerstone program for transition-age youth with serious mental illness: study protocol for a randomized controlled trial,” Trials 17 (2016): 1-13.
[iii]Yolanda Anyon et al., “Health Risks, Race, and Adolescents’ Use of School-Based Health Centers: Policy and Service Recommendations,” The Journal of Behavioral Science & Research, 40, no. 4 (2013): 458.
[iv] Frank and Glied, Better But Not Well, chap. 6.
[v] Ibid., chap. 3.
[vi] “Suffering in the Streets,” New York Times, September 18, 1984.
[vii] Christine Montross, “The Modern Asylum,” New York Times, February 18, 2015.
[viii] Frank and Glied, Better But Not Well, chap. 7.
[ix] Fatos Kaba et al., “Disparities in Mental Health Referral and Diagnosis in the New York City Jail Mental Health Service,” American Journal Of Public Health 105, no. 9 (2015): 1911-1916.
[x] Ibid., 1911.
[xi] Lee-Ann Fenge et al., “Mental health and the criminal justice system: The role of interagency training to promote practitioner understanding of the diversion agenda,” Journal Of Social Welfare & Family Law 36, no. 1 (2014): 41-43.
[xii] Frank and Glied, Better But Not Well, chap. 4.
[xiii] Suzanne Koven, “Should Mental Health Be a Primary-Care Doctor’s Problem?” New Yorker, October 21, 2013, accessed March 28, 2017.
[xiv] “Mental Health First Aid” NYC Health. http://www1.nyc.gov/site/doh/health/health-topics/mental-health-first-aid.page
[xv] “Mayor de Blasio Permanently Establishes Mental Health Council,” NYC.Gov, March 31, 2016. http://www1.nyc.gov/office-of-the-mayor/news/315-16/mayor-de-blasio-permanently-establishes-mental-health-council
[xvi] “Thrive NYC: Year One Update.” The City of New York. https://thrivenyc.cityofnewyork.us/wp-content/uploads/2017/02/Thrive_Year_End_Updated-1.pdf
[xvii] Allen J. Frances, “World’s Best and Worst Places to Be Mentally Ill,” Psychology Today, December 28, 2015, https://www.psychologytoday.com/blog/saving-normal/201512/worlds-best-and-worst-places-be-mentally-ill
[xviii] “Connections to Care,” NYC.Gov, http://www1.nyc.gov/site/fund/initiatives/connections-to-care.page.
[xix] Norah Vincent, Voluntary Madness: Lost and Found in the Mental Healthcare System (New York: Penguin Books, 2010), 19.
[xx] “Mental Health and Integration,” The Economist Intelligence Unit (2014). http://mentalhealthintegration.com/media/whitepaper/eiu-janssen_mental_health.pdf
