May 3, 2023
Half a year with the street counselors who dispense free sneakers, monthly injections and gentle encouragement to some of the city’s most vulnerable and volatile residents.
Andy Newman and Hiroko Masuike followed mental health field teams for months as they treated homeless clients in Brooklyn, Manhattan, Staten Island and Queens.
Chris Payton and Sonia Daley emerged from the subway into the brilliant sunshine to meet a client nesting on a pile of blankets near the Staten Island Ferry terminal in Manhattan.
It had taken their team almost five months just to track down the 43-year-old homeless woman, chasing leads from the police and other homeless people. On this afternoon last August, they were trying to help her find the holy grail: an apartment where someone with a severe mental illness could build a stable life.
The woman, M, flashed them a big smile. In her black baseball cap, long blond wig, oversize sunglasses and about 20 bracelets, she looked like a misplaced movie star.
M, who has schizoaffective disorder, immediately began chattering. She said she was doing great, thanks to Mr. Payton: “He gave me a million-dollar bill in cash, so I’m living off that.” Her boyfriend sat beside her, rocking and weaving, one gloved hand in constant motion as if conducting an invisible orchestra.
Her visitors were from a street team of clinicians, called an Intensive Mobile Treatment team, who deliver a vast array of services — medical, social, material, logistical, spiritual — to some of the city’s most vulnerable and volatile residents. They asked that M be identified only by her initial.
Intensive mobile treatment is a mostly unheralded but crucial component of Mayor Eric Adams’s attempts to tackle the overlapping crises of mental illness and homelessness. It is also a gentler, more holistic complement to blunter tactics that have grabbed more attention, like sending the police and sanitation workers to tear down encampments and taking people to hospitals against their will.
There are 31 such teams, run by nonprofits under contract with the city, ministering to over 800 people, with a wait list of 250 more. In March, Mr. Adams said the city would add five more teams, to serve another 135 people. The teams’ clients have struggled with homelessness and mental illness or substance abuse and often have criminal or violent histories. They live their lives both at the city’s very margins and at the chaotic intersections of dysfunctional bureaucracies.
There are other street programs that serve precarious New Yorkers; I.M.T. is for the toughest cases.
Over the course of seven months, two teams that share a Brooklyn office let a reporter and photographer shadow them. The teams’ workers meet clients where they are, at shelters and hospitals, train stations and park benches. They go along to court dates and housing interviews and inject them with antipsychotic drugs on street corners.
They buy them chopped-cheese sandwiches and flip phones and warm socks — anything to keep clients engaged. Their job, said Ashwin Vasan, the city’s health commissioner, is to be the glue that holds together the pieces of a fractured life.
“What this really comes down to is accompaniment,” Dr. Vasan said. “Am I able to walk beside you in your journey?” I.M.T. teams, he said, “follow the ethos of ‘whatever it takes.’ There is no problem that isn’t their problem.”
The city has found that the teams help people find stability, but the road there is steep and littered with obstacles. Hospitals discharge psychotic clients without notice. Shelters let benefit applications expire. Paperwork disappears.
That August afternoon by the ferry, M’s consciousness streamed out in a childlike voice. “When I wake up I’m not hungry; when I wake up I’m not excited or sad,” she told Mr. Payton and Ms. Daley. “The way I sleep is I sleep on my back with my hand or arm around my head. That’s important — my relaxation and that will help you determine with what kind of housing you give me.”
Sometimes M seemed to say the opposite of what might be true. “I don’t have a mental history of schizophrenic bipolar because my parents, they did great, and I didn’t grow up in an abusive household,” she said. “Nobody didn’t punch nobody when the money ran out.”
No matter how far into fantasy M wandered, Ms. Daley — a type of counselor called a peer specialist — and her boss, Mr. Payton, 50, the team’s program director, guided her back toward the practical.
To qualify for housing, they explained, she needed to go with them to a Social Security office. They could also help her get disability benefits. M enthusiastically agreed.
“I’m glad you’re willing to work with us,” Mr. Payton said.
“My job position is I’m a prim executive director,” M said. “I don’t mind sleeping on the blanket, but every day I want to access my wealth and go to work.”
“You have great work experience,” Mr. Payton said, adding, “We’ll try to help you make your goals.”
M flashed into coherence.
“My goal is just to think clearly and not be schizophrenic and not be on drugs so that you can talk to me and get your point across and you can understand my disposition and what I’m trying to say,” she said.
Mr. Payton and Ms. Daley gave M water and chocolate bars and tuna and fruit cocktail. They gave her a tent. Then they bid her farewell and spent most of the rest of the day chasing a client who had checked himself into a hospital, checked himself back out and disappeared. The man resurfaced days later.
Their team, Team Richmond, works out of a narrow, cluttered office on the second floor of an unmarked building in Brownsville, Brooklyn, flanked by a shuttered soul food restaurant and a storefront church. By the door downstairs, a photo is posted of a client who threatened the staff. “Do not let this guy into this building!” it says.
Team Richmond cohabits with another Intensive Mobile Treatment unit, Team Prospect, run by the same nonprofit, the Institute for Community Living. One morning in July, Team Prospect workers traded updates.
A client named Oscar had been standing in the lobby of his building shouting, “What happens in Manhattan stays in Manhattan!” A woman who was under a “Kendra’s Law” order requiring outpatient treatment had disappeared again.
Lauren Schultz-Kappes, Team Prospect’s program director, said that the woman had recently agreed to get her monthly medication injection. “Then over the weekend she just texted everyone — myself, the shelter director — saying she’s going to put us in a meat grinder.”
The city Department of Health and Mental Hygiene launched three I.M.T. teams in 2015 to help people whose complex needs were not met as they cycled through hospitals, shelters, jails and the streets. In 2021, as the pandemic took a toll on public mental health, the city added 28 more teams.
Unlike similar programs, intensive mobile treatment is funded directly by the city, not Medicaid, which gives it flexibility. If a client says they want to “be a rich and famous rapper, we will write that — that’s your goal,” said Bridgette Callaghan, a vice president of the Institute for Community Living who oversees its six teams. “We’re not into the business of reframing things so that it sounds clinically justifiable.”
For a team’s 27 clients there are nine staffers, including three social workers, a psychiatrist or nurse practitioner and two peer specialists — like Ms. Daley, 51, who became a peer specialist after her own struggles with depression and anxiety.
The approach is not cheap. The cost — about $37 million annually — works out to about $840 per client per week.
But consider some of the alternatives. A week of inpatient care for schizophrenia or bipolar disorder at a city-run hospital costs roughly $13,000. A week at Rikers Island jail costs in the vicinity of $10,000.
Most I.M.T. clients are homeless. As of September, about 30 percent of those who were homeless when they enrolled in the program had moved into housing, the city said. The clients were also considerably less likely to be incarcerated after enrollment than before, the city said.
One of the hardest things a team must do is to win the trust of clients scarred by years of bad encounters with the system.
“We meet people where they are, whatever they need in the moment,” said Jody Rudin, the Institute for Community Living’s president. “If they’re hungry, we give them food. If they’re cold, we give them a sweatshirt.”
One day in August, Ms. Schultz-Kappes and several members of her team piled into a van and headed out to see clients: a man who once made headlines for throwing urine at a police officer; a homeless shelter resident with a manslaughter rap; a pregnant woman who needed her monthly shot of a schizophrenia drug.
As the van crawled through traffic, Ms. Schultz-Kappes got a text and yelled from the front seat, “They’re discharging Brandon!”
Brandon Jackson came to the team in March 2022 after two years on Rikers Island for beating and robbing a woman. He got off to a rough start. He sent the staff photos of him cutting himself. He sold his risperidone, a flattening antipsychotic not known for its recreational appeal. Now he was hospitalized after attacking someone at his shelter.
The night before, a hospital psychiatrist had emailed Ms. Schultz-Kappes that he “continues to have little insight and is resistant to treatment.”
I.M.T. teams usually try to help clients avoid hospitalization, but sometimes they push hospitals to hold them longer. “The hospital is like ‘Nope, they’ve been here for five days. They’re taking their meds. They’re not a danger,’” Ms. Callaghan said. “And we’re like, ‘The second they leave, they’re going to throw their meds in the garbage.’”
The constant loop of progress and backsliding can be overwhelming, Ms. Schultz-Kappes said. “But it’s just keeping in mind: These clients have been through so much and don’t have anyone, and even just seeing little progress, like someone reaching out when they’re in crisis or answering the phone —— ”
Grace Coviello, the team’s psychiatric nurse practitioner, finished her sentence: “It’s like counting little tiny baby wins.”
Over time, sometimes, the wins add up.
After Mr. Jackson’s hospitalization, he stayed on his medications.
“It’s just a great time right now,” he said on an office visit in late December. He hoped to get his high school equivalency diploma, then a job. In February, Mr. Jackson, 32, moved into a shared supportive-housing apartment run by the Institute for Community Living. His new life had begun.
For most clients the city assigns to an I.M.T. team, the intervention comes after decades of trouble.
M grew up in Chicago; her mom drove a school bus and her dad was a roofer. He had bipolar disorder and abused M’s mother, said M’s sister, who asked to be identified as Marie, her middle name.
M had two children very young, at 14 and 15. She worked briefly in a hair salon. She got into drugs. When she hit her 20s, her family saw something wasn’t right.
At gatherings, “she would be so happy,” her sister said. “Then all of a sudden she would be like ‘I can’t take this anymore’ and she would just up and leave and wouldn’t return until the next day. And she wouldn’t remember what happened.” At her first hospitalization, she received a diagnosis: schizoaffective disorder, bipolar type.
Her life ever since, her sister said, has been punctuated by medicated periods of relative lucidity, hospital stays, jail stints for prostitution and other minor crimes, and long stretches lost in a fog. Once she took off for Miami to live the high life. “Sometimes she feels like she’s a celebrity,” Marie said.
In 2020, while living with Marie in Wisconsin, M asked for money to go shopping. The next her sister heard from her, M was in New York. She stayed for a while in shelters on Staten Island but was hospitalized briefly after she spat on another shelter resident. For the next two years, M seldom slept indoors, except in train and subway stations.
In recent months, Mr. Payton had been urging her to try supportive housing and got her a phone interview with a prospective landlord. The interview did not go well. M learned that the apartment was temporary and that she would need to stay on medication and meet with a case manager.
Before the interview, Mr. Payton said, M was lucid. Once it started, she began rhapsodizing about moonbeams in Florida.
“Her way of saying no and not wanting to deal with people is to go into psychosis,” he said.
It would have been easier to get M an apartment if she were medicated, and a team can ask a judge to mandate outpatient treatment, including medication, under Kendra’s Law.
But I.M.T. teams tend not to want to coerce their clients.
“Would I prefer that she be in a shelter?” Ms. Callaghan said earlier this year. “Yes. But this is the life that she is actively choosing to live.”
In November, the police found M yelling threats at passers-by. She was hospitalized in Brooklyn for three weeks.
During that time, Mayor Adams announced a policy to remove homeless people with severe mental illness from the streets, drawing mixed reviews. Before M was discharged, she was given an antipsychotic injection that lasts a month, Ms. Callaghan said. When Ms. Daley visited her at the foot of an escalator just inside the Court Square subway station in Queens right before Christmas, she was still largely coherent and considerably more subdued.
Ms. Daley was there to do M’s application for disability income. It was 30 pages long. For the employment section, M mentioned her job at the hair salon.
“What are some of the hairstyles you did?” Ms. Daley asked.
“Dreads, sew-ins and short haircuts,” M said.
“In this job, did you use machines, tools, equipment?”
“I used curlers.”
After Ms. Daley left, M phoned Mr. Payton.
“Chris, I’m just calling to see if the housing is going to go into effect so I can know when I’m moving,” she said in a voice mail message.
In early February, a spot opened in a temporary home in Coney Island run by the institute that offered a fast track to permanent supportive housing.
M could have it, with one caveat: M’s boyfriend, Stanley, could not live with her if they were not married or registered domestic partners.
M agreed to give it a try. Ms. Daley went to get her at a subway station.
“Have you told Stanley?” Ms. Daley asked.
“Stanley, I’m going with Sonia,” M said.
Stanley and M looked searchingly at each other.
“I’ll stay,” M told Ms. Daley.
“Stay where?”
“Here. With him.”
Ms. Daley left them. “When I was doing the training to be a peer specialist, they said there’s three needs that a person has to have — a home, love and a job,” she said. “And this is what she found: She found love. And it’s heartbreaking to separate them.”
Three freezing days later, M called: Was the bed still available? It was.
“I changed my mind because I wanted to have something,” M said as she arrived in Coney Island with Ms. Daley, looking nervous but determined. “I want to go back to school. I want to do something with my life.
Mr. Payton was not with them. He had quit a few weeks before to work for another social-service agency for more money, though he said he “loved the job” running an I.M.T. team.
The house in Coney Island was on a quiet street. Inside it was newly renovated, spotless. The hosts greeted M warmly.
“She came in smiling, so that’s good,” the house’s evening coordinator, Tessie Brennan, said as M took a shower. The scent of dinner cooking filled the house.
They showed M her room — a double, but M was the first woman to move in, so Ms. Brennan told her to pick a bed.
“This bed,” M said, sitting on it. It had a festive orange spread.
M had a lot of questions. When would she get permanent housing? Would she have an apartment with a balcony?
Ms. Daley said she would try to get a phone for Stanley and connect him with services. M thanked her.
“I feel fulfilled of my job with what I have accomplished today,” Ms. Daley said as she headed home.
The next day, M signed herself out and did not return. The program gave her bed to someone else.
M went back to camping in Queens for a few weeks. On a chilly Monday in March, Ms. Daley escorted her back to Penn Station. This time, her sister in Wisconsin had bought her a ticket home. M blew Ms. Daley a kiss goodbye as she boarded the train.
Read via The New York Times.
