8th Annual Lillian Wald Symposium Asks: How Do We Meet the Need for Mental Health Services in NYC?
By Raaziq Brown
Panelists for the 8th Annual Lillian Wald Symposium (Left to Right): George Aumoithe, Jose Cotto, Jo-Ann Abrams RN, MS, CRNP, Omar Fattal, MD, Arvind Sooknanan, and moderator Andy Newman.
The 8th Annual Lillian Wald Symposium, held Wednesday, April 12, convened a panel of diverse experts with frontline experience in the mental health field. The discussion surfaced a dramatic range of challenges to providing appropriate mental health care to those who need it and broached solutions that crossed the health system, housing, and medical research fields.
Henry Street Settlement President & CEO David Garza, in kicking off the symposium, said that his team members are witnessing the impact and devastation of mental illness on the populations they serve throughout the agency’s programming, from direct counseling to workforce, aging, and afterschool, to arts services.
Lillian Wald, a nurse and the founder of Henry Street Settlement, “felt it was a responsibility to bring people to the table to talk about critically important issues and mental health,” Garza said. Social issues related to mental illness are not new but have been exacerbated by the pandemic, which left people with feelings of loss, isolation, disruption, and unpredictability. For a significant part of its history, Henry Street has offered mental health care. Its Mental Hygiene Clinic, now called the Community Consultation Center (CCC), opened in 1946, and was one of the first community-based mental health clinics in the country, located in public housing at 40 Montgomery Street.
Moderator Andy Newman, social services reporter for The New York Times, introduced the five panelists:
- George Aumoithe, assistant professor in the Department of History and the Department of African and African American Studies, Harvard University
- Jose Cotto, senior vice president for residential treatment at the Institute for Community Living
- Omar Fattal, MD, system chief for behavioral health and co-deputy chief medical officer, NYC Health + Hospitals
- Jo-Ann Abrams RN, MS, CRNP, psychiatric nurse practitioner at Henry Street’s CONNECT program
- Arvind Sooknanan, board member and community advocate at Fountain House
Defining the Mental Health Crisis
Newman asked panelists to define the mental health crisis. Jo-Ann Abrams RN, MS, CRNP, who provides street-level care both through Henry Street and the Bronx Intensive Mobile Treatment (IMT) team, responded, “It’s in chaos. The structure and foundation that I’m used to seeing is totally gone.”
With regard to people on the schizophrenic spectrum who require long-term treatment, Abrams said she has had difficulty getting access to care. Patients are hard to get admitted into the emergency room, are frequently discharged, the length of stay has been cut from the usual four weeks to as little three days, and discharges are abrupt. Moreover, patients are being seen by professionals who are not familiar with necessary medications and do not often receive follow-up outpatient services, she said. Dr. Omar Fattal countered that city hospitals do extensive evaluations and keep the patients for as long as needed.
Abrams provides street-level care with a team of mental health professionals, including a “peer” who helps calm clients who have a lack of trust in providers. Schizophrenic patients are often criminalized, she says, yet they are not criminals; they are people have been poorly treated by our mental health system. In addition, use of cannabis, K2, and heroin, added to delusions and hallucinations, makes it difficult to diagnose.
“What makes this a crisis is the mismatch between the need and the workforce.”
Abrams added that patients also encounter pushback from pharmacies that sometimes don’t have access to the appropriate medication and stigmatize patients attempting to receive medication because they are homeless or lack support.
Staffing Shortages Are a Major Factor
“What makes this a crisis is the mismatch between the need and the workforce,” panelist Omar Fattal said. The conditions of the pandemic led to medical professionals increasingly choosing remote work over work in the field, and many people who were able to retired. The pandemic has shown a simultaneous increase, Fattal said, in both prevalence of mental health–related conditions and awareness. This awareness has led to more people coming forward seeking help with their mental struggles, but the staffing does not meet the demand. He echoed Abrams, saying that drug use has proved to be a major factor affecting schizoaffective patients.
“There was an 80% increase in overdose deaths between 2019 and 2021,” Newman said, when asking the panelists about data that shows the crisis worsening.
Fattal explained, “children have been affected the most.” An increase in suicidality, anxiety, self-injury, and depression among youth has severely changed our communities, and the youth component plays a major part in the increase in the need for mental health support.
Panelist Arvind Sooknanan is not only an advocate and board member of Fountain House but also a participant in the Bronx Club House who lives with mental illness. Diagnosed with schizophrenia at 16, Sooknanan recalled the difficulty finding a psychiatrist or therapist who took his insurance and met his needs as well as the class and racial disparities he faced as the child of low-income immigrants.. Between 15 and 19 years old, Sooknanan was hospitalized over 20 times.
“When I was in those facilities, I saw one or two types of patients. One type was usually wealthy, white kids, and the other were kids that looked like me,” Sooknanan says. The latter often received no outpatient plan, no continual care or support, and had nowhere to go. To receive adequate support, Sooknanan had to travel upwards of an hour and a half from the Bronx, a hurdle that is common for people of his community.
Henry Street Settlement and Fountain House provide the type of community-based care that panelists consistently acknowledged is essential, but the need is much greater than available resources. Sooknanan said that 90% of Fountain House members are of color and that this factor played a pivotal role in his finding comfort there.
“Every other mental health facility I went to, I felt as if I was speaking to a prosecutor,” Sooknanan said.
“I don’t think the crisis is larger than it was before. It’s always been there. For decades this has been a problem. Across the country, there are 14 million people living with a serious mental illness diagnosis. The access to care has only gotten worse because of the pandemic,” he added.
New York state has the most psychiatrists in the nation, said Sooknanan, yet many people do not have access to care for myriad reasons: insurance, overwork and burnout of staff members, and more. Sooknanan said there are two separate tracks for people in the health care system: those with mental illnesses and those with serious mental illnesses. Both sides have their own narratives and stigmas attached to them, which can make the work difficult.
Sooknanan relayed his experience of police intervention during a mental health episode he had his teen years. Although he was in his home, unaggressive, and barely clothed, the police tackled him and put him into handcuffs.
“Does it make sense when someone is really struggling… to have a man with a gun show up? I would get more scared, wouldn’t you…? I can’t emphasize the importance of trust and community,” Sooknanan said.
Mayor Adams’s push to use police officers and clinicians to remove mentally ill individuals who pose a risk to themselves or others from the street met with heavy blowback and criticism from advocates and community members. Fattal said, however, that, with more than 50,000 patients arriving in public hospitals for behavioral services a year, he has not seen an increase in their numbers. These hospitals have been increasingly connecting patients to the New York state Office of Mental Health–run Transition to Housing Unit (THU), where people can go after a time in a psychiatric inpatient unit—and to the Extended Care Unit at Bellevue and a similar unit that just opened in Kings County Hospital. Patients can stay up to 90 days on the Extended Care Units
New York state has the most psychiatrists in the nation, yet many people do not have access to care.
The Historical Context for Today’s Crisis
The Lillian Symposium traditionally includes a historian who places the theme of the event in its historical context. Around 1855, said panelist George Aumoithe, was the first time in American history that the idea emerged of hospitals providing long-term mental health services for people on the schizophrenic spectrum.
“A lot of the things that we are missing today existed between 1855 and 1940,” he said, such as a commitment among institutions to care for the mentally ill, a donor base in the community, and people who saw the hospitals as places where they could claim care for their loved ones. There was racism and abuse in these facilities, but there was also compassion and care across a long time frame. A shift began in the 1940s to emphasis on community care—a time when, Aumoithe said, there were only eight Black psychiatrists in the United States.
Practitioners like Lillian Wald were trailblazers for community-based nursing, which brought health professionals into homes and on the street, while building longstanding social relationships with their patient families.
By the 1960s and the Civil Rights Movement, Aumoithe said, state hospitals were closed due to the perception that hospitals for the mentally ill were places where people were being abused, despite that they were the only places where people could get long-term care.
In 1963, the Kennedy Administration passed the Community Health Act, promoting a version of community care, says Aumoithe, that “was not necessarily in line with Lillian Wald’s vision but was more in line with a vision of cost cutting and penny pinching.” That led to people being cast out of hospitals on a broad scale. As a result, we end up where we are today, said Aumoithe: the mentally ill being viewed as “street people” or criminals.
Aumoithe said that today’s tension between the rehabilitation versus criminalization of people with mental illness dates back to the 1970s—as the nation’s reinvestment in hospitals converged with the War on Drugs. “This is the very moment that the population not connected to long-term care is being seen as the source of racial violence, a problem population and incarcerated.”
Needless and syringe exchanges of the ’80s and ’90s had to go through a district attorneys office before they could open. The pattern of criminalization instead of rehabilitation, says Aumoithe, repeats today with Mayor Adams’s authorization for the NYPD’s to remove people with mental illness from the street.
Cotto and Aumoithe both addressed the role of racism in mental health care. Cotto noted that the history of racism in health care—from the Tuskegee study of Black men to today’s unequal access to Covid education and vaccines to Black maternal mortality—also applies to mental health care.
What the System Is Missing
Panelists shared ideas on what the mental health care system in New York City is lacking. Cotto described the extensive hurdles that those with mental health challenges need to overcome to find supportive housing. Abrams emphasized the need for education and research in the sector. She noted that many nurses are not being trained to handle patients on the schizophrenic spectrum—and some are seeking easier jobs, which decreases the quality of mental health services. Adequate education of nurses and all mental health professionals would cover the gap in knowledge that is needed to properly take care of patients, she said.
Abrams added that there is not enough research being done on schizophrenia. “We are only guessing,” she said, and do not know what schizophrenia is caused by. “Without knowing the source, it is difficult to put preventative measures in place for these patients.”
“We need more staffing on all fronts, more housing and less shelters, integrated care, more funding, and more nursing,” Cotto said. “There is a need for behavioral health to be treated with the same intensity as physical health.”
The current crisis has been shaped around intervention instead of prevention, Sooknanan said, which boils down to a lack of value in the continuum of care. Sooknanan believes that when people get out of the hospital there should be a plan for their stabilization that focuses on crisis prevention.
An Abundance of Solutions
Panelists shared their thoughts on actionable solutions that can improve the mental health care system today, beginning with fighting stigma.
“This reminds me of the HIV crisis,” Abrams said. In the last few years, the mental health crisis has received a lot of media attention, but stigmas surrounding mental health have not changed. Having a mental illness “doesn’t define you. You are not your illness,” Abrams said.
Jose Cotto noted that far more resources need to be provided to both patients and health care professionals to solve this crisis. There is a need for more community hubs, leveraging misused housing to create spaces for healing and making the profession more attractive to broaden the applicant pool for new staff.
Ultimately, Cotto says, there needs to be the same emphasis on mental health as we place on physical health: We need more psychiatric beds, including those that were taken offline during the pandemic, more nursing, and more supportive housing beds. Still, he says a number of creative solutions are under way. Manhattan Psychiatric Center beds have been converted to a THU, the 90-day unit where people can continue to recover after an inpatient stay.
Fattal believes that the current discussion of the mental health crisis at state and local levels is finally bringing attention to a long-neglected issue, and that things may be getting better. He is seeing an opportunity for the mental health system to expand, with hospitals listening to psychiatrists and mental health practitioners whose issues sometimes evade the spotlight. In the recent past, he said, the governor and mayor have prioritized this issue, and funding is following. NYC Health + Hospitals has been working to expand outpatient services, reopen beds, expand substance abuse treatment, and expand street homeless outreach van programs.
Sooknanan noted the need for more “community-based care like Fountain House and Henry Street.” Community-based care can be an effective solution, he said, because it reduces expenses for patients while giving access to education, employment, health and wellness, and other social services.
“We should focus on crisis prevention, and that includes taking down stigma,” Sooknanan said, to conclude the discussion.
To view the panel discussion in full, click here.
