Top: Ramon Rivera is flanked by police after his arrest. Bottom: Evidence markers at the scene of a stabbing.Mother Jones illustration; Sam Costanza/New York Daily News; Kyle Mazza/TheNEWS2/Zuma (2)
On the morning of November 18, New York City police reported that a man fatally stabbed three people in a seemingly random spree in Midtown Manhattan. The victims included a construction worker in Chelsea, a man fishing along the East River, and a woman sitting on a bench near the United Nations headquarters. A cab driver witnessed the third attack and alerted police, who arrested Ramon Rivera and recovered two large kitchen knives. Rivera was charged with three counts of first-degree murder.
In the days following, a picture of Rivera emerged in the press: a 51-year-old homeless man who had cycled in and out of the criminal justice system. He had been arrested at least eight times in the last two years, mostly for minor charges, and had recently spent several months in Rikers Island jail for burglary and attempted assault. Rivera’s record also showed a history of serious mental health issues—he spent some of his previous sentence in a psychiatric ward and in 2023 had told police that he was feeling suicidal and homicidal, according to the New York Times.
“That’s a wake-up call for our criminal justice system and our psychiatric system,” New York City Mayor Eric Adams said at a press conference shortly after the attacks. “We have three New Yorkers who were murdered in our city by a person who was betrayed by the health care system, and that should trouble us all.”
Faced with an uneasy public, Adams seized the opportunity to defend his controversial 2022 directive that expanded standards for when someone can be involuntarily removed from the street to be evaluated for psychiatric treatment. At that same press conference, Adams described this as a humanitarian measure that had successfully prevented violence and once again called for the passage of the Supportive Interventions Act, which would codify those expanded standards into state law. But legal advocates and disability rights groups say this is a misguided response to rare, though undeniably horrific, acts of violence. They worry that these incidents will be used to justify what they say often is the traumatic and unnecessary removal of New Yorkers who are simply experiencing homelessness.
“These are isolated instances,” said Ruth Lowenkron, director of the disability justice program at New York Lawyers for the Public Interest. “It doesn’t mean that we should decide that everybody with mental health diagnoses are scary and that we have to ensure that they are off the streets.”
November’s attacks were consistent with the profile of other widely covered killings in New York: an alleged assailant who spent years cycling between homelessness and jail, punctuated by stints in an underfunded and overburdened mental health system. In retrospect, the moments when tragedy could have been averted—if only the system had worked as it should—may appear to be obvious, but they rarely are. New York is not alone in attempting to address these challenges. For decades, lawmakers throughout the country have grappled with how to balance the civil rights of those with mental illness with protecting the public.
The involuntary commitment process may begin with an encounter like the hypothetical Adams posed in the 2022 press conference announcing the removal directive. He described a person “talking to themselves” on the street, “unkempt” and without shoes, perhaps “shadowboxing” with someone who isn’t there. Under New York law, a police officer or medical professional can determine whether the person poses a “substantial risk” to themselves or others. If they do, a police officer can arrange for that person to be transported by emergency services, even against their will, to a hospital for psychiatric evaluation. Once at the hospital, doctors have 72 hours to assess whether the person meets a similar standard of risk and should be treated involuntarily.
Involuntary commitment has long been a controversial measure. There are broad concerns that it infringes on an individual’s civil liberties and can be a distressing and traumatic experience—potentially discouraging further mental health care. Advocates argue that there are more effective, less traumatic ways of engaging people through community-based services, though they are fragmented and have suffered from a lack of investment. Studies tracking the impact of involuntary treatment have found mixed results for patient well-being, and some report links to a higher risk of suicide.
Proponents like the Treatment Advocacy Center, which has pushed for stronger commitment laws around the country and has been criticized by patient advocacy groups, argue that involuntary treatment can save lives and prevent people with serious mental illness from deteriorating even more. Lisa Dailey, the group’s executive director, claims that this can also avert future run-ins with law enforcement because “failing to get somebody admitted for care really just makes criminalization more likely.”
Dominic Sisti, a professor of medical ethics at the University of Pennsylvania, said the effectiveness of involuntary treatment depends greatly on the specific circumstances of the patient and the quality of care. Involuntary treatment is intended to be a last resort, after voluntary pathways have been exhausted, but each state has its own criteria.
There have been efforts to revisit these standards around the country. Last year, California Gov. Gavin Newsom signed a law expanding the standards for forced treatment to include severe substance use disorder and an inability to provide for one’s personal safety or medical care. Earlier this year, Florida legislators approved a bill that eased the commitment process and widened the pool of medical professionals authorized to order involuntary treatment.
“The problem with legislating treatment of people with mental illness in order to prevent crimes is that you have to identify them.”
But the question of whether involuntary commitment can prevent violence is a complicated one. Dr. Dinah Miller, a professor of psychiatry at Johns Hopkins School of Medicine and a co-author of Committed: The Battle over Involuntary Psychiatric Care, said, “The problem with legislating treatment of people with mental illness in order to prevent crimes is that you have to identify them.” Almost inevitably, Miller said, this will result in the commitment of some people with no risk of violence.
In New York, the turn to involuntary psychiatric treatment in the wake of a shocking act of violence stretches back to at least a 1999 subway killing. Kendra Webdale, a 32-year-old journalist, was pushed in front of an oncoming subway in Lower Manhattan by a man with a history of serious mental illness. Webdale’s death led Brian Stettin, a young lawyer at the New York state attorney general’s office, to draft Kendra’s Law, which allows court-ordered outpatient psychiatric treatment when there is a risk of violence.
But 20 years later, another subway shoving was evidence to many that the state had not done enough. In January 2022, Michelle Go, a 40-year-old business consultant, died after being pushed in front of an oncoming subway in Times Square by a homeless man who had cycled through hospitals and jails. It was mere weeks into Adams’ first term. Stettin, who had become the Treatment Advocacy Center’s policy director, penned an op-ed describing the incident as “depressingly similar” to Webdale’s death and calling for New York to “broadly interpret” civil commitment laws. That July, Stettin was named the mayor’s senior adviser for severe mental illness.
The appointment was an early sign that involuntary commitment would be the center point of Adams’ approach to mental illness. In November 2022, the mayor ordered police, EMS, and mobile crisis teams to follow expanded standards for involuntary removal and commitment. The new criteria were based on a memo released that February by the New York State Office of Mental Health, which sought to address what it described as a “misconception” that involuntary evaluation and treatment is allowed only when there is a threat of violence. It said existing case law supported involuntarily removing people “who display an inability to meet basic living needs, even when there is no recent dangerous act.”
In an interview with The City shortly after Adams’ announcement, Stettin said the directive was not “operationally” different from current practices. All it was doing, he said, was informing service providers and police officers that “you have more ability to help people than you may have realized.”
Criticism was swift. Beth Haroules, a senior staff attorney at New York Civil Liberties Union, argued that the directive effectively lowers the standard for involuntary removal. Advocates worried that the “basic needs” criteria would apply to people who were simply experiencing homelessness, leading to the removal of those who may be sleeping on a park bench or in a subway car. Yung-Mi Lee, legal director at Brooklyn Defender Services, said the measure could lead to significant numbers of people who don’t need hospitalization becoming mired in the psychiatric system. “It blurs the line between just being unhoused versus somebody who’s truly mentally ill,” Lee told me.
Some worried the measure would lead to more encounters between law enforcement and people experiencing homelessness, which could rapidly escalate. “Police are not mental health crisis interventionists,” Haroules said.
City hall spokesperson William Fowler underscored that the directive was a matter of providing humanitarian services, saying in a statement: “Denying a person life-saving psychiatric care because their mental illness prevents them from seeing their desperate need for it is an unacceptable abdication of our moral responsibility.”
There are significant concerns about what inpatient psychiatric care currently looks like in New York, as hospitals face critical staffing shortages. (Staffing has been a major obstacle to reinstating psychiatric beds that were removed during the pandemic.)
Advocates also have pointed out that involuntary treatment is a temporary measure—an emergency involuntary admission lasts 15 days, though it can be extended—and that after they are discharged, people receive little support. Community-based mental health services have long been underfunded, and a lack of coordination has resulted in some people falling through the cracks. This is not news to the mayor, and Adams has recognized that resources are needed throughout the system. Stettin told The City, “When people tell us that the city has a long way to go to kind of build that continuum of care that meets all levels of need and ensures that people receive care in the least restrictive, appropriate environment, they’re preaching to the choir.”
Two years later, advocates have acknowledged that there does not seem to be an influx of people being involuntarily committed. According to the mayor’s office, an average of 126 people per week were involuntarily removed between January and October of this year, but the city was not systemically tracking removals before the 2022 directive. In March 2023, a police official reported to the New York City Council that in the first few months following the removal directive, Black people made up 47 percent of those who had been involuntarily transported while only being 23 percent of the city’s total population. (This roughly resembles the demographics of those experiencing homelessness.)
Last year, the NYCLU sued the New York Police Department for the release of its policies and procedures around involuntary removals, which is still pending. The city council also passed a law requiring annual reports outlining who is being involuntarily removed and whether they are ultimately admitted to a hospital. The first set of data is expected in January.
Haroules, the NYCLU lawyer, said the lack of transparency makes it difficult to evaluate whether the measure is as effective as the mayor insists—or as harmful as advocates worry. She suggested that the measure may have been a “smoke and mirrors” effort to signal to commuters and tourists alike: “Come to New York. It’s safe. You’re not going to run into people in the subways.”
Following November’s attacks, Adams gave a full-throated defense of the removal directive. “Everybody said I was inhumane, that we just want to institutionalize people. Well, this is the result of that,” Adams said at a press conference. “Too many people were afraid to step up and say people who are dealing with severe mental health illness need to get the care they deserve, even if it means involuntary removals. I was not willing to sit back and allow this to continue to happen, and the thousands we removed off the streets prevented incidents like this.”
Come January, the state legislature will be considering two involuntary commitment measures. One is the Supportive Interventions Act, which Adams has repeatedly championed, even though it has not gained momentum since being introduced in the state Assembly in 2023. In addition to codifying “basic needs” standards into state law, it would widen the pool of medical professionals who can authorize involuntary treatment and would allow some shelter staff to initiate removals. There is also the HELP Act, announced after November’s attacks, which seeks to expand who can evaluate a patient for involuntary treatment without changing the standards. But advocates are still concerned about this proposal, setting up a difficult path forward for both bills.
In the meantime, the humanitarian problem will only worsen as temperatures drop in New York. Advocates agree with Adams on one crucial point: We should not walk past someone who is clearly in need of help. But they fear that extreme weather will justify more involuntary removals, which they say ultimately does little to address why people are on the streets in the first place.
“I don’t want to see people who are homeless either,” Lowenkron, the NYPLI lawyer, told me. “But my answer isn’t to sweep them off the street.”
