$1 Billion for Mental Health: The Reality of de Blasio’s ‘Revolutionary’ Plan

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On his now-frequent tours of early presidential primary states, Mayor Bill de Blasio has taken to invoking a less-familiar aspect of his tenure: a nearly $1 billion plan to address mental illness in New York City.

Mr. de Blasio’s wife, Chirlane McCray, has done the same, presenting the effort as a national model to audiences from Atlanta to Seattle.

The mental health initiative, known as ThriveNYC, is crucial to Ms. McCray’s potential as a future political candidate, and has become increasingly important to Mr. de Blasio as he toys with a possible 2020 presidential bid. He now regularly names Thrive as one of his administration’s core achievements.

“It’s revolutionary,” Mr. de Blasio told CNN’s Symone Sanders during a recent forum at Harvard University.

But back home, the effort, now in its fourth year, has sputtered. The plan, which includes dozens of discrete programs across 15 city agencies, has undergone two leadership changes in the last year; the most recent saw a top official from the Police Department, Susan Herman, taking charge last month.

Ms. McCray will likely face tough questions on performance and spending during a special hearing of the City Council on Tuesday. The city comptroller is also investigating.

For all the talk, the initiative has been less sweeping than envisioned: A third of the budget has not been spent, according to an analysis of city data by The New York Times. Repeatedly presented by City Hall as a four-year $850 million plan, city officials now say $560 million will have been spent in that time.

The biggest challenge for Mr. de Blasio and Ms. McCray has been to identify concrete results. A spreadsheet of nearly 500 data points tracked by City Hall included almost none related to patient outcomes.

City officials, for example, could not say how many people have been connected to treatment after calling the city’s new mental health hotline, because fewer than 10 percent agree to a follow-up.

“It is a hard thing to measure, because it’s never existed before,” Ms. McCray said in an interview at Gracie Mansion last month. “So, what are the right measures?”

At least one available barometer hinted at the challenges that the city still faces in dealing with mental illness: More New Yorkers dialed 911 to report a person in the midst of a mental health crisis last year — 179,000 calls — than at any point in more than a decade.

Public health officials credit the plan for drawing attention to mental health, often too easily ignored by political leaders. Ms. McCray, for example, seldom talks about Thrive without imploring audience to repeat the number of its mental health hotline, 1-888-NYC-WELL.

At the same time, some initiatives failed to get started, while others placed unrealistic demands on already strained mental health services.

“Are we there yet? No,” Dr. Gary Belkin, a top health official and the chief of policy and strategy for Thrive, said of using the hotline to connect people to care effectively. “But we’ve built the structure that can get us there.”

Much of the development of Thrive was personal, born of Mr. de Blasio’s and Ms. McCray’s own difficulties navigating the mental health system on behalf of their daughter, Chiara, who struggled with depression and drugs during high school and college.

“It was not as obvious what I, as first lady, would take on; I wanted to take on something big,” Ms. McCray said in the interview. That first year, she began talking with Dr. Belkin. She took a mental health first aid course in October 2014.

Over the next four years, Ms. McCray would transform herself into a mental health evangelist.

“What do they always tell you when you’re in high school or in college? You should choose to work on something that you would do without pay,” she said. “And guess what — I finally found it.” (She receives no pay for her city work.)

Not all of the programs in her plan were new. The city invested heavily on mental health before the de Blasio administration: For example, the Health Department spent $243 million in the 2014 fiscal year on mental health contracts. With Thrive, spending rose to $346 million in fiscal year 2018, according to an analysis by the City Council.

Besides the ramped-up spending, a big part of Thrive has been Ms. McCray’s advocacy. She has traveled the city urging New Yorkers, particularly in black and Hispanic communities, to open up and to erase the stigma around mental health. She occasionally speaks of her own experience with therapy, and in the interview, she spoke obliquely of her brief return to treatment last year. “Something happened that triggered the need for me to go,” she said without elaborating. “I felt like I was not able to function.”

But City Hall is still struggling to quantify the payoff from her efforts. Dr. Belkin said that while suicide rates are not the best measure, the Health Department has been looking at trends in suicide attempts, based on emergency room visits. Officials are also collecting survey data. (According to data provided by the city, surveys of about 10,000 callers to NYC-WELL since late 2016 found about 60 percent felt better after calling the number.)

One indicator of the need for services: The phones at NYC-WELL ring constantly, 180,000 times in 2018, according to city data. (Some are repeat callers, with a few who call as many as 200 times a day.)

The call center, operated under city contract, took over the old Lower Manhattan offices of a city suicide hotline known as LifeNet, a service with calls that peaked at 105,000 in 2014. During a recent visit, a screen played YouTube videos of adorable animals, to help soothe staff members who work in sound-dampened cubicles. The service also includes text and web chat.

People can receive confidential crisis counseling and referrals. But the interaction is not therapy, cautioned Dr. Anitha Iyer, who helps oversee the call center. “That’s a misconception that people often have,” she said.

Few of those who dial the number agree to a follow-up call, making it hard to gauge its effectiveness. So far, almost all of the information on follow-up care comes from the limited cases in which a social worker and psychiatrist have been sent to visit the person.

And even some experienced in mental health services have been surprised at what the service does not offer.

A retired psychiatric social worker dialed NYC-WELL last year hoping for a nonpolice response for his 37-year-old son, who had been making threats and had a history of manic episodes. The father asked for a psychiatrist and a social worker to be sent to the home.

He was told a team like that could not come for at least a day, maybe two; for immediate help, call 911.

“They sent a whole army of police,” said the father, who asked to be referred to only by his first name, Ralph, to protect his son’s privacy. Initially, his son refused to cooperate. “That escalated the situation,” he said. The officers eventually brought him to Elmhurst Hospital, nearby.

Mental health advocates have been pressing the city to overhaul how emergency personnel respond to situations involving people experiencing the effects of severe mental health issues. But the police are still often the only ones available to respond quickly to calls, even to the mental health line.

The Thrive program budgeted millions to create diversion centers, a place other than jail for officers to bring those experiencing a mental health crisis.

But problems with the city’s initial proposals delayed the process, those involved said. Two locations have been selected, in East Harlem and the Bronx, but neither has opened yet. More than $15 million has been budgeted over the last three years for the effort; none has been spent.

“They have good ideas, but the implementation is what they stumble on,” said Steve Coe, the chief executive of Community Access, which provides housing and other services to the mentally ill.

Thrive’s primary focus is on the other end of the spectrum: New Yorkers who have less serious and possibly undiagnosed mental health problems, a population that according to City Hall encompasses 1.7 million city residents.

To serve that population, the city is spending $12 million a year on the NYC-WELL hotline — not including nearly $11 million spent on advertising in 2017, mostly to promote the service.

Another prominent element of Thrive is an expansion of mental health first aid training. Health Department employees now conduct the eight-hour classes daily at churches, schools and community centers.

Ms. McCray implores those she meets to take the course, which includes discussions and role playing. So far, she has not been able to get the mayor to take it. (“He’s kind of busy,” she said.)

But the vast majority of city spending on the program goes to more than 40 other endeavors, such as a crime victim advocate program; social and emotional learning in public schools; and a corps of young behavioral health clinicians paid by the city to work at nonprofits for three years.

Even as the city has poured money into mental health programs and training, nonprofit directors said they still struggle with providing treatment, citing inadequate Medicaid reimbursement rates and even less generous reimbursements from commercial insurers. Some have closed their doors; others have chosen to stop providing mental health services.

David Woodlock, president of the Institute for Community Living and a former top state health official, praised Ms. McCray for her courage in taking on mental health issues. But he bemoaned the inadequacy of state funding, and called the city’s contracting process broken.

“People are being asked to do more in this system that is not built for expansion,” he said.

Helping the seriously mentally ill remains a challenge, especially in a crisis. Those moments often involve the police, and have led to confrontations where officers have been injured, and the person the officers came to help getting physically hurt or killed.

During one such episode in 2012, a man whose family members called 911 to try to help him, attacked one of the responding officers, stabbing him in the neck and face.

The man, Benedy Abreu, 31, served five years in prison and is now in a program funded through Thrive to help those with serious mental illness and a criminal past. He receives regular visits from a psychiatrist and a peer counselor.

“Everyone in life goes through something,” said Stacey Hamilton, 52, a peer specialist and social worker, reassuring Mr. Abreu during a recent visit that he, too, could become a peer counselor and recalling her own history of mental illness and incarceration.

Later, she wondered aloud whether her work with men like Mr. Abreu would be enough. “If this is the highest level of care,” she asked, “how many success stories are there really?”