New York City Mayor Eric Adams unveiled a controversial policy last month to force people with severe mental illnesses off city streets and into hospitals. Already the Bazelon Center for Mental Health and other patients’ rights advocates are pushing back, worried the policy focuses more on reducing visible homelessness than helping people access mental health care.

The situation also hearkens to a long-standing dilemma in the mental health world: how to balance the right to refuse treatment with the social responsibility of cities to care for some of their most vulnerable residents – even when they decline care.

Here is where Washington state currently stands when it comes to treatment and what policies in New York could mean for Seattle and Washington state.

What does Washington’s current law say about committing people against their will?

Under Washington’s Involuntary Treatment Act, a person may only be involuntarily committed to care if a designated crisis responder, or DCR – a mental health professional with the specific role of determining whether someone should be committed – assesses them and finds them to be a threat to themselves, others or property, or if they are “gravely disabled.” That standard means the person with mental illness is not able to care for basic needs like sleeping, bathing or eating, and is getting worse.

Many families struggling to get loved ones into treatment complain that the bar is too high, and say they’re told nothing can be done if there’s not an immediate safety threat. DCRs in Washington are also often overextended and can’t respond quickly to calls from community members.

Other people, though, advocate fiercely for people’s right to have control over their own medical care and warn of a slippery slope toward warehousing people in psychiatric institutions.

“I have a lot of concerns about how we’re reaching quickly for commitment legislation,” said Laura Van Tosh, a local advocate and leader in patients’ rights, who also has a bipolar diagnosis.

She sees the recent moves as an effort to just get rid of visible homelessness.

“All of this has come with (a) different political flavor than care,” she said.

In 2018, Ricky’s Law went into effect, aimed at helping people with substance use disorders who meet a similar threshold to the one outlined under the Involuntary Treatment Act. Under Ricky’s Law, people are involuntarily taken to secure withdrawal management and stabilization facilities to detox, typically from alcohol, methamphetamines or opiates.

According to a report from the Washington Health Care Authority, 961 people received treatment through Ricky’s Law between October 2020 and September 2021.

What does the New York City law say? Has this been tried before?

New York City’s new policy is still playing out. While mental health advocates agree there’s a desperate need for improved access to mental health care, some point to research that finds forced treatment can be traumatizing and lead to worse outcomes for people with mental illnesses.

In many states, courts stipulate people must be in “imminent danger” as part of the threshold for commitment.

Mayor Adams is now citing a memo that was released by New York’s Office of Mental Health in February, stating law enforcement is able to detain people with severe mental illnesses and transport them to a psychiatric hospital “even when there is no recent dangerous act.”

The proposal is already being challenged in court: The New York Times reports that a civil rights law firm argues the mayor’s plan would lead to people being “forcefully – often violently – detained” by officers with “little to no expertise” in handling mental health crises.

New York City has made similar attempts before and met resistance. In 1987, Mayor Ed Koch announced a similar program to force people with severe mental illnesses into treatment, but advocates with the New York Civil Liberties Union stepped in and ultimately the policy was rescinded.

What other issues pose a challenge for this kind of effort?

If people are pulled off the street and detained, there needs to be a place for them to go to receive care. But there is a severe shortage of psychiatric beds for people in crisis around the country, especially for youth and people with dual diagnoses that include substance use or intellectual and developmental disorders. Washington is no exception in needing more psychiatric beds: In King County alone, there are 111 fewer residential mental health beds today than there were in 2018.

Workforce issues are a major factor: Even when there are beds, it’s difficult to staff them. The need for more mental health professionals spans all types of care, from therapy to inpatient.

The Kaiser Family Foundation estimates the U.S. needs an additional 7,800 psychiatrists to meet the current need, and the National Center for Health Workforce Analysis estimates that by 2030, the country will need about 12-15% more social workers, addiction counselors and psychiatric nurse practitioners to meet future demands.

What do Seattle and Washington state officials say about this move?

Could we see something like that here in Washington? It’s unlikely, at least in the near term.

Gov. Jay Inslee’s mental health efforts have been aimed at building up care options in the community, rather than expanding the state’s large psychiatric institutions. For example, while Western State Hospital is undergoing a major renovation project, the state is transitioning the facility to focus on serving people coming through the criminal court system. People who haven’t been accused of a crime but are committed involuntarily through the civil courts should go to community-based facilities instead, under the plan – though there are questions about how available those options will be.

Asked about the New York City proposal, Inslee’s office told The Seattle Times: “Involuntary commitment is a last resort – we need to put first things first in Washington. Our behavioral health and hospital systems are over capacity. Our priority must remain capacity-building.”

The governor’s office also said it would like to see more investment in wraparound services – aimed at not only helping people with mental health concerns but also providing social supports like housing or employment assistance – and community-based behavioral health, as well as more support for mental health workers. The governor’s office said Inslee’s upcoming budget proposal, to be announced next week, will prioritize behavioral health.

Seattle Mayor Bruce Harrell’s office told the Times, “Seattleites feel the impacts of our capacity constrained behavioral health system on the streets far too often.”

But to address those issues, he pointed instead to building out the local crisis care system: King County and Seattle-area officials recently proposed a tax levy to fund five walk-in crisis centers across the region if voters approve the measure come April. Those centers would serve people seeking care voluntarily.

“Our priorities include a focus on delivering care to those most in need, ensuring there are suitable places for people to go, and increasing treatment capacity,” Harrell’s office said in a statement. “We’re committed to advancing proven solutions like those proposed in the King County plan to invest in behavioral health.”