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Insanity in New York

Each successive round of deinstitutionalization has released sicker—and potentially more dangerous—mental patients to languish on the streets.

Before he murdered Kendra Webdale, the New York Civil Liberties Union probably considered Andrew Goldstein a success story.

Goldstein was first admitted to a New York mental hospital in 1989 after a spell of erratic behavior culminated in pushing his mother into a wall. After doctors heard his symptoms—paranoia, sensory distortions, hallucinations, violent outbursts—they diagnosed him with schizophrenia.

Goldstein’s symptoms could be managed with medication, but the drugs came with unpleasant side effects. His one-time roommate Larry Termo said the antipsychotic drug Haldol caused Goldstein to have “spasms where he [would be] twisted almost totally into a pretzel.”

He deteriorated in the years after his first stay in the hospital. Goldstein spent most of the next decade being admitted to—and, with the help of civil libertarians, promptly discharged from—mental hospitals and emergency rooms. All the while, he heard voices, assaulted strangers, and pleaded in vain to be institutionalized.

Goldstein went off his medication in 1992, accelerating his downward spiral. He committed himself to the state-run Creedmoor Psychiatric Center, a ramshackle campus in Queens that once housed over 7,000 patients. According to hospital records, Goldstein was “extremely dangerous and potentially violent,” assaulting three staff members and exhibiting intense paranoia. Goldstein locked himself in the nurses’ station for fear staff would poison him with cyanide.

He didn’t stay long. The New York Office of Mental Health (OMH) was under fire from the NYCLU and lawyer-activists like Bruce Ennis, whose stated goal was “nothing less than the abolition of involuntary hospitalization” and the closure of institutions like Creedmoor. OMH wanted Creedmoor and other state “Psychiatric Centers”—a network of large state-run hospitals dating back to the 19th century—to release patients and accept fewer admissions. The state reportedly instituted discharge quotas to avoid litigation from advocacy groups.

Within a year of his admission, Creedmoor released Goldstein to a step-down unit on grounds, and by 1994, he was on the streets again and off his medication. Despite his documented history of violence and paranoia, he had little contact with outpatient clinicians or social workers.

Two years later, an unmedicated and unstable Goldstein assaulted a customer in a supermarket. He was sent to a psychiatric ward in a general hospital and subsequently discharged. He punched two people in a Burger King and assaulted a doctor and female patient in another psychiatric ward. According to New York Times reporter Michael Winerip, medical records describe Goldstein “constantly attacking strangers” and “lashing out for no reason to [sic] people he doesn’t know.”

Goldstein’s sensory distortions, one of the hallmark symptoms of schizophrenia, worsened in the succeeding 18 months—he described seeing people shrink and grow. He began hallucinating. For a while, he thought he was the Italian composer Ottorino Respighi. Goldstein went on to commit 13 assaults in the next year and a half and was sent to the emergency room ten times. In his medical records, doctors described Goldstein as a “danger to self and others” and a “high risk for violence.” Each time, Goldstein was released back into the community with no supervision.

In 1997, in the mental health system’s last brush with Andrew Goldstein, he was sent to the psychiatric ward of Brookdale Hospital, a general hospital in Brooklyn, after attacking a stranger in a subway station. He told staff he needed full-time supervision and wanted to be transferred back to Creedmoor. Creedmoor agreed Goldstein needed institutional care but had no space available because of bed cuts. Goldstein was once again discharged with antipsychotic drugs and an outpatient referral.

In January 1998, after repeated pleas for help and a decade-long spree of violent outbursts and assaults, Goldstein killed Kendra Webdale, shoving her in front of the oncoming N train in the 23rd Street subway station.

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Two weeks ago, a man known to police as Martial Simon allegedly killed a woman, pushing her in front of a moving subway train in New York City. Simon was homeless and had an outstanding warrant for violating the terms of his probation. His sister told the New York Post that Simon has schizophrenia and had “been in and out of mental hospitals for more than 20 years.” She once “begged a hospital not to release him due to his potential for violent behavior.” The hospital let him go anyway. As he was led in handcuffs to the police station, a bug-eyed Simon stuck his tongue out at photographers and claimed to be God. He’s in Bellevue now, awaiting trial.

Simon’s arrest comes months after a schizophrenic woman named Anthonia Egegbara allegedly pushed a man into a moving subway train in Times Square. Egegbara had been hospitalized more than 50 times since she was a teenager. Local reporting reveals a spate of incidents involving mentally ill defendants in New York assaulting strangers.

New York’s Office of Mental Health is now in the ninth year of its “Transformation Plan,” a departmental initiative to decrease the already dwindling populations of New York’s state-run Psychiatric Centers and serve more New Yorkers in “home and community-based settings.” OMH Commissioner Ann Marie Sullivan said in 2017 that one of the department’s goals is to promote “mental health…awareness, and social inclusion.” The drafters of the report said their goal was to create a “modern, progressive mental health system” in New York.

A “transformation plan” may have been warranted in 1955. Then, Brentwood’s Pilgrim Psychiatric Center had almost 14,000 patients. Creedmoor had almost 7,000. There were some 558,000 patients living in America’s public mental hospitals, almost 95,000 of whom lived in New York asylums.

Today, as the late D.J. Jaffe said, “it is harder to get into Bellevue than Harvard.” The most recent respective daily censuses at Pilgrim and Creedmoor are 262 and 303. In a state of 19.4 million people, there are about 2,200 budgeted adult civil beds across New York’s 17 State Psychiatric Centers. By any conceivable metric, the system has already been “transformed.”

As people with untreated schizophrenia languish on street corners, scream at figments in train stations, and push strangers in front of subway cars, it is almost unthinkable that New York would further reduce its inpatient psychiatric capacity. But that has been its response. OMH, which did not respond to an interview request, released monthly status reports on its transformation plan after its launch in fiscal year 2014-15. The earliest report available online (March 2016) and the latest (October 2021) reveal the extent to which New York has reduced its state-hospital capacity in pursuit of a “modern, progressive mental health system.”

Between March 2016 and October 2021, New York State shed 301 beds at its Psychiatric Centers—more than 8 percent of its previous budgeted capacity. The average daily census at its state hospitals dropped by 503, a 14 percent decrease. These bed cuts were felt hardest in New York City. Of all the Psychiatric Center beds cut in the state of New York between March 2016 and October 2021, nearly 50 percent were in New York City.

Compared with the mammoth declines of previous decades, a 300-bed cut in state-hospital capacity might seem small. But the remaining patients served in New York’s mental facilities are, as a group, sicker than any round of previously discharged patients. These patients have managed to be committed to a state mental hospital in an era where every major power center in mental health services—federal and state law, departmental bureaucrats, lawyers, patient advocates, nonprofit advocacy shops, federal advisory agencies, and most of the Democratic Party—is arrayed against “institutionalization.” These patients would not be hospitalized but for demonstrated need. With so few beds in its Psychiatric Centers, each successive New York bed cut is more likely to spring a dangerous patient or prevent the state’s most unstable from accessing long-term psychiatric care.

New York and states across the country are grappling with “diminishing returns” to deinstitutionalization. The first major wave of psychiatric deinstitutionalization in the United States was generally successful. In the early part of the 20th century, it was possible to have someone committed to a mental hospital for reasons now considered trivial, like “burnout,” promiscuity, and “hysteria.” Before the rise of skilled-nursing facilities and memory-care homes, adult children often sent their demented parents to a state hospital to live out the twilight of their natural lives. Discharging these patients involved little risk to the public at large and was often a humanitarian imperative.

After these patients were discharged, however, each successive round of deinstitutionalization released sicker—and potentially more dangerous—groups of mental patients onto the streets. E. Fuller Torrey, former ward psychiatrist at Washington’s St. Elizabeths Hospital and the founder of the Treatment Advocacy Center, described this phenomenon in his book The Insanity Offense:

The patients released in the later years [of deinstitutionalization] tended to be those who were sicker, who had fewer social supports, and who were less likely to be aware of their illness and take medication. On the basis of this scenario, one would expect to find the earliest adverse effects of deinstitutionalization appearing in the early 1970s, then to see these effects increase sharply over the following two decades. This is exactly what we find.

Many discharged patients did well in the community. Others did not. The hospital closures and bed reductions left many seriously ill patients like Andrew Goldstein, Martial Simon, and Anthonia Egegbara to ping-pong through emergency rooms and community facilities until they finally snapped and hurt someone. But deinstitutionalization advocates in New York and elsewhere refused to back off of their agenda. To its proponents, deinstitutionalization is not a matter of rebalancing a lopsided system. It is a crusade. Mike Gorman, the head of President Truman’s Commission on the Health Needs of the Nation, once said his “hidden agenda was to break the back of the state mental hospital.” In New York, they’re still grappling with Gorman’s success.