New York's Office of Mental Health announced a department-wide "transformation plan" in 2014. The goal was to reduce the number of beds in New York's State Psychiatric Centers, a network of public hospitals dating back to the middle of the 19th century, and expand "community-based" treatment options for people with serious mental illness. OMH hoped the plan would create a “modern, progressive mental health system."

Between April 2014 and December 2022, the number of budgeted beds at New York's public mental hospitals fell by more than 22 percent. New York, a state of more than 19 million people, was left with fewer than 2,300 public psychiatric beds across seventeen state hospitals. By comparison, the average daily census at just one of those hospitals, Creedmoor, was upwards of 6,000 in 1955.

The statewide efforts to increase "community-based" care, in tandem with pandemic-related surges in non-psychiatric admissions, led many general hospitals to reduce the number of beds on their psychiatric wards over the same period of time. According to OMH, about 850 of those beds were cut during the pandemic, and have not returned since.

When deinstitutionalization began in New York and across the country in the early 1950s, the risk that a bed cut would spring a dangerous patient, or prevent a dangerous person in the community from accessing needed long-term psychiatric care, was relatively small. The number of people living in large state-operated asylums far exceeded the number of people who actually needed long-term residential psychiatric care. Until the Social Security Act was amended in 1950 to require participating states to create licensing standards for nursing homes, for example, the elderly were often committed to state hospitals when their care became too burdensome for their adult children.

Today, by contrast, when beds are already scarce and states are straining to divert institutional admissions, each successive bed cut is more likely to either spring, or prevent from accessing needed care, the sort of person who is an actual danger to himself or others. This principle was illustrated by the several high-profile incidents of lethal violence committed by people with psychotic illnesses in New York last year.

In response to those incidents, Governor Kathy Hochul acknowledged the need for reform, and announced plans to expand the state's inpatient capacity. New York City Mayor Eric Adams, whose staff declined an interview request, issued a directive to law enforcement to take into custody people demonstrating dangerous signs of mental illness. Then, last October, after repeated incidents of violence involving people with untreated mental illness in the New York subway system, Hochul and Adams announced a joint plan to improve subway safety. Some of their proposals were predicated on the same "community-based care" dogmatism that helped to create the state's mental-health crisis, such as their proposal to creation of two 25-bed "step-down" units at state mental hospitals to return "street and subway patients" to "enriched li[ves] in the community."

The most recent mental-health-related tragedy on New York's subway system illustrates the failure of the state's approach. Jordan Neely, a schizophrenic with an outstanding felony warrant and forty-two arrests related to public disorder, was reportedly threatening other members on the F Train before several riders restrained him, later leading to his death.

Neely's experience with "community mental health care" was in line with the goals of OMH's "transformation plan." Neely was reportedly involved with the Bowery Residents' Committee, a nonprofit group that links the area's homeless population to housing and "specialized mental health services." He had also been "in and out" of Bellevue, the city's safety-net hospital, several times, for what presumably were short stabilization stays. And when Neely's aunt reportedly tried to get him "more intensive care," she was "thwarted by doctors and the medical system," who insisted upon releasing him back to the community.

It should have been obvious that Neely needed long-term residential care—not just a 72-hour "stabilization" period—given his rap sheet of psychosis-related criminal behavior and his family's repeated pleas for "more intensive care."

But unfortunately for people in need of such care, there is an ideological component to the debate over inpatient psychiatry that extends beyond the practical question of how best to serve people with serious mental illness. For certain disability-rights activists, one purpose of closing beds at state-operated mental hospitals is to facilitate encounters like the one between Jordan Neely and the people on the F Train. Proponents see deinstitutionalization as a way to spark social change—paradoxically, to use a person with untreated serious mental illness, and the disruption they cause to public order, to "treat" the intolerance and close-mindedness of the masses.

A recent essay by David Thacher, on Mayor Adams's proposal to expand involuntary psychiatric treatment in New York City, summarized disability-rights advocates' view of deinstitutionalization as being

a movement that aimed to restructure social institutions and community practices to make it possible for people with a wider range of physical, cognitive, and emotional capabilities to live alongside one another, rather than consigning them to segregated institutional settings. The target of that effort was not individual change but social transformation. It insisted that we should not view people with psychiatric disabilities simply as patients to be cured but as citizens who must be included in society as equals. It required more than new ways of dispensing psychiatric services in the community. It required supportive housing, flexible jobs, responsive schools, capable families, tolerant communities, and other social arrangements that make it possible for people who differ from the “average” tenant, worker, student, son or neighbor to succeed in their role.

In this view, it is society, and not the mentally ill person, that is "sick." And "treating" that "sick" society—making it capable of true tolerance and inclusion—requires exposing society to people like Jordan Neely, who make it uncomfortable and test its ability to "tolerate" disorder.

Emma Vigeland of the progressive Majority Report podcast, for example, recently described being elbowed in the face on the subway by a man having a psychotic episode. She said that she "was a little scared," but argued that the "primary object of what we should be focusing on" in such situations is "the fact that this person is in pain." Focusing on the person's disruption of other people's safety "privileges the bourgeois concern of people's immediate discomfort in this narrow, narrow instance as opposed to larger humanity and life" and indulges in the "politics of dehumanization."

It is thus a mistake to think of the downsizing and closure of state mental hospitals as exclusively a judgment about the most appropriate setting for mental-health care. It is also intended as a provocation, to test society's willingness to tolerate disorder, even at the expense of a person wasting away in delusion.

The question that matters in this case, and cases like it, is what society should do with people like Jordan Neely. What cities around the country are learning the hard way is that people with treatment-resistant schizophrenia are often not best served by a 72-hour hold in a general hospital's psychiatric ward. What they know, but refuse to learn, is that such people often need asylums, in the benign sense of the word.

We should not return to the state hospitals of 1955, with overcrowded wards, compulsory shock treatment and lobotomies, and lifetime commitments. Many of the state hospitals of 2023, which rely almost exclusively on pharmacological interventions and chemical restraints, are also less than ideal. What we should defend, for the small group of people with persistent, serious, treatment-resistant psychosis like Jordan Neely, are the state hospitals founded and envisaged by Dorothea Dix in the 19th century: Rural campuses, with manicured grounds and stately buildings, where people with serious mental illness in need of medium- to long-term residential care can find a place of refuge.

New York still operates at least two of these kinds of facilities, Creedmoor and Pilgrim Psychiatric Centers, built in the 19th century on Dix's model of pastoral asylum care. For the people in the system who consume the national conversation on mental illness—people like Jordan Neely, who ping-pong between emergency rooms, jails, psych wards, and street corners—the solution may be a return to the system's roots.