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For mentally ill in New York, jail means care

THE BALTIMORE SUN

NEW YORK -- In the hours when even New York City sleeps, buses roll onto a seedy block on the Queens side of the 59th Street Bridge, where the only signs of life are a dozen prostitutes, the gang members who run them, a doughnut shop hang-out and a stripjoint with brawny bouncers.

The buses arrive every hour of pre-dawn funk between 2 and 6 a.m. They come from Rikers Island, the city-run compound that, houses the biggest jail in the country. And they are carrying just-released prisoners to their first concrete slab of freedom.

Many of them have nothing more than what the guards handed them on the way out the door -- a card worth two rides on the subway.

For some, that's enough to get where they're going. But others have nowhere to go.

Many of the passengers have some form of mental illness. While at Rikers, they received psychiatric care and medicine. On release, though, with very few exceptions, they too are given nothing but the subway card: no drugs, prescriptions or referrals.

For them, the bus stop in Queens has long been the revolving door between a turbulent life on the streets and the relative respite of jail.

"I see a lot of these guys over and over," the Rikers bus driver said after a drop-off one recent morning.

In an era when many mental institutions have shut down because of civil-liberties lawsuits and conservative budget cuts, jails have become, as the title of a Soros Foundation study last year put it, "Hospitals of Last Resort."

A growing phenomenon

It is a growing phenomenon in many cities, nowhere more than in New York.

Thirty years ago, there were a half-million beds in mental hospitals nationwide, about 90,000 of them, or just under onefifth, in New York state.

Now, according to Heather Barr, a lawyer for the Urban Justice Institute and author of the Soros study, New York state has fewer than 5,000 beds.

Probably not all 90,000 of those beds needed to be filled back then. And some of those who might have ended up in hospitals at an earlier time are finding care in outreach centers, outpatient wards or other facilities.

But many of the untreated have wound up in jail, arrested for petty crimes, a trend that has grown since Mayor Rudolph Giuliani instituted the policy of prosecuting quality-of-life" crimes such as drinking or urinating in public, sleeping on the street, and jumping subway turnstiles.

Over the course of a year, 33,000 inmates in New York City's jails, a quarter the total number, receive mental health services while locked up. About half of those have serious ailments.

Of the 20,000 prisoners in Rikers Island alone, 2,500 have chronic, menta disorders - making the jail, Barr said, "de facto the state's largest psychiatric facility,"

The difference is that New York state law requires psychiatric facilities to provide a "discharge plan" to patients who are released to the outside world: a drug regimen (usually paid for by Medicaid) and a referral to a doctor, clinic, or shelter.

Jails have no such obligation.

The Urban Justice Institute has filed a class-action lawsuit requiring the city to provide this assistance to mental patients released from jail, as well.

New York Supreme Court Judge Richard F. Braun recently ruled in the institute's favor, agreeing that the distinction between jails and hospitals is meaningless these days. He also declared that withholding assistance from released inmates causes "irreparable harm," and results in "substance abuse, mental and physical health deterioration, homelessness, indigence, crime, re-arrest, and re-in-carceration."

The city's lawyers have appealed the ruling.

Ethan Ward, 37, arrived at the Queens bus stop one recent day at 5 a.m. He had served 15 days at Rikers for selling marijuana to an undercover policeman. Ward hears voices in his head, and suffers from severe mood swings. He was given medicine for these ailments while at Rikers; the city has a contract with St. Barnabas Hospital to treat mentally ill prisoners there.

But, he said, "When they let me out, they didn't give me anything but the subway card."

Ward had been living in a men's shelter in Washington Heights, where he receives medication daily. He used the subway card to go back there.

No recourse

Juan Serrano, 40, who was let off in Queens at 3 a.m., had no such recourse. He avoids shelters; he'd slept in one a few years ago and nearly got killed. So he walked toward the subway station, unclear what to do.

"I don't want to break the law again," he said. "But if it gets cold, I'm going to have to find a hallway someplace to sleep in."

Estimates vary widely on the number of homeless adults in this city - around 15,000 in shelters and another 5,000 to 15,000 on the streets - but most analysts figure one-third to one-half of them are mentally disturbed.

The issue has taken on a high profile in the past couple of years, as a schizophrenic, Andrew Goldstein, killed Kendra Webdale by pushing her off a subway platform; a homeless man named Bently Louis Grant allegedly hit Tiffany Goldberg on the head with a brick and a still-unidentified man did the same to Nicole Barrett. All these incidents occurred in midtown Manhattan in the middle of the day.

Not long ago, such assailants would have been in mental institutions rather than out in the public. The fact that they were walking the streets is the result of a strange history.

It started as far back as the late 1940s, when books like "The Shame of the States" and movies like "The Snake Pit" revealed the gruesome conditions in many mental asylums.

Then, in the late 1950s, Thomas Szasz, a professor of psychiatry, wrote an influential book, arguing that mental illness was a myth - the result of psychiatric diagnoses, not real conditions.

Around this time, antipsychotic drugs, such as Thorzine, hit the market, suggesting that mental hospitals might not be necessary for many patients.

In 1963, President John F. Kennedy signed a bill setting up "community mental health centers." All but the sickest patients could be discharged from hospitals, receive treatment from these centers instead, and go about living normal lives.

However, as Dr. Howard Telson, a longtime forensic psychiatrist at Bellevue Hospital and professor of psychiatry at New York University, put it, "A lot of the funding never got to the community health centers, but patients got released from hospitals anyway."

This trend was accelerated by a string of court decisions in the 1960s and 1970s, ruling that the mentally ill could not be involuntarily committed or forced to take their medication, unless they posed a danger to themselves or to others. Subsequent rulings made it harder and harder to prove they posed a danger.

All this was compounded by increasingly conservative legislatures, which slashed mental health budgets for both old-fashioned hospitals and new-style community centers.

By the 1980s, the result, Telson said, was "a national crisis, massive homelessness, and total neglect."

Walter Dickey, a law professor at the University of Wisconsin, wrote an article for the Criminal Law Bulletin in 1980, predicting that many of the people let out on the streets would commit petty crimes and find themselves shunted into the criminal-justice system, and that - as Barr's study confirmed 20 years later - mental hospitals would be replaced by jails.

Norman Siegel, head of the New York Civil Liberties Union, filed many of those lawsuits to keep mentally ill people from being involuntarily committed. Asked recently if he had second thoughts about the consequences of these lawsuits, Siegel replied, "We think about it a lot." However, he blames the government for "reneging on its promise to provide mental health centers - that's the problem."

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