Editor's note: Since this article was originally published in the print edition of The Progressive, Eric Adams has ended his mayoral re-election campaign and endorsed Andrew Cuomo in the race.
In early May, less than two months before New York State Assemblymember Zohran Mamdani’s surprise victory in New York City’s Democratic mayoral primary, rumors swirled that the candidate wanted more homeless people to sleep in the subway.
The New York Post editorial board wrote at the time that Mamdani’s idea for repurposing long-vacant retail spaces in subway stations as crisis and drop-in hubs would “make sure even more mentally ill homeless people are constantly thronging the subways.” In City Journal, the Manhattan Institute’s Jesse Arm referred to the candidate and his coalition as “people who think it’s good, actually, to have more mentally ill homeless folks sleeping in the subway.” And The Atlantic described Mamdani as “a socialist who wants to use subway stations to house even more homeless people than they currently do.” [The Atlantic has since edited this line without providing a correction note for the change.]
In reality, Mamdani has never advocated for unhoused people to take shelter in the subway system. His proposed $10 million initiative would create stations meant to connect the unhoused people already there with “longer-term support,” encouraging them to access treatment or shelter programs outside of the train stations. This is ultimately a small piece of Mamdani’s flagship proposal: the Department of Community Safety, for which he says he would budget $1.1 billion funded by both a high-income tax hike and a consolidation of existing programs. The department would address mental health care access, homelessness, and crime prevention through expansion of non-police support services and emergency response, but would not affect the New York City Police Department’s $5.53 billion allocated budget or staffing.
It’s an entirely different approach to mental health policy than the “involuntary treatment” initiatives gaining steam across the country—and supported by Mamdani’s two major opponents, incumbent New York City Mayor Eric Adams and former New York Governor Andrew Cuomo. As nearly a quarter of adult New Yorkers experience a mental health disorder in a given year, Cuomo and Adams have each promised to make major investments in mental health care. But both have said they would expand the use of involuntary psychiatric treatment and maintain police involvement in mental health emergencies.
Mamdani’s plan would instead restructure and expand funding for mobile crisis responders, subway outreach units, peer staff who have personally experienced mental health crisis and recovery, as well as “clubhouses” that coordinate treatment, housing support, and transitional employment in a supportive social community. Combined with increased funding for community-based psychiatric care, substance abuse treatment, and supportive housing, Mamdani says the Department of Community Safety would balance the dual need for crisis care and more preventive services.
Adams, on the other hand, has framed his extensive efforts as mayor to forcibly remove people with mental illness from public spaces as a signature achievement of his tenure. Cuomo vociferously defends the use of police in street removals and civil commitment, as well. In a campaign video from August, he is seen telling an unhoused person on the street, “We gotta get you some help, man,” before he appears alongside police officers at the scene. “Don’t tell me that the NYPD isn’t needed,” he spits into the camera, accusing other, unnamed politicians of “defunding” and “demonizing” the police.
Cuomo’s and Adams’s embrace of involuntary treatment—which includes both involuntary hospitalization and court-ordered outpatient treatment, and can involve forcibly medicating people—is part of a nationwide shift in both municipal and state mental health care policy over the past decade. While expansion of involuntary treatment is widely favored on the right, it has also gained substantial ground in blue states such as New York, California, Oregon, and Washington, where mental health crises and addiction have become increasingly visible.
This spring, a little more than a year after she announced a $1 billion increase in statewide mental health care funding, New York Governor Kathy Hochul pushed state lawmakers to loosen the legal criteria for involuntary treatment. The new criteria now encompass those who are not an imminent danger to themselves or others but cannot meet “basic needs such as food, shelter, and medical care.” In 2021, then San Francisco Mayor London Breed declared a state of emergency in the long-neglected Tenderloin neighborhood to more easily force unhoused people into treatment. The next year, California Governor Gavin Newsom implemented a statewide “CARE Court” system, which compels some individuals with mental illness into treatment under the threat of being placed into conservatorships. In Chicago, police-initiated hospitalization increased by more than 30 percent between 2023 and 2024 alone, with more than 20 percent of police responses to mental health calls resulting in forced hospitalization.
State by state, a similar shift has played out: Legislators lower the threshold for who can be coerced into treatment, while municipalities encourage police and other emergency responders to make use of the lower threshold by having more unhoused people evaluated for civil commitment. In July, President Donald Trump brought involuntary treatment to the federal level, issuing an Executive Order to remove some restrictions on the use of civil commitment.
Caught against a powerful current, Mamdani—who has expressed skepticism about expanding involuntary treatment, though he respects its use as a last resort—has hastened to defend his radical approach against those who have labeled him unserious and impractical.
But while supporters of involuntary treatment expansion have framed themselves as the “adults in the room” on this issue, they have largely failed to engage with the available evidence. Despite a long history of forcing people into medical care in the United States, there has been virtually no empirical research on the efficacy of involuntary psychiatric treatment due to the ethical and logistical minefield of attempting to study non-consenting patients. We do know that involuntary patients tend to receive poor-quality treatment that relies heavily on the use of antipsychotics and other psychiatric medications. But the process of involuntary treatment, often involving a court order, can be so traumatic and destabilizing that patients become distrustful of clinicians and eventually refuse to continue treatment once they are given the choice.
Those who are willing to continue treatment are frequently left to fend for themselves in a decayed, byzantine system with few accessible options. Inpatient treatment itself does little, if anything, to address patients’ material needs—food, shelter, employment, and community—though these needs are increasingly presented as the very justification for forcing people into treatment. As a result, the mental health of already vulnerable people often deteriorates as they become trapped in a revolving door between periods of civil commitment, incarceration, and homelessness. All of this would be bad enough if it were cost-efficient. But the costs associated with involuntary hospitalizations and other emergency psychiatric treatment are astronomical, burdening both the state and the patients themselves.
Due to growing demand and community advocacy, many cities and states have already attempted to implement some of the alternative programs that Mamdani supports. In the past decade, a number of cities, including New York City, Chicago, Minneapolis, and Denver, have launched mobile crisis teams designed to respond to mental health-related 911 calls, with social workers trained in de-escalation and homeless outreach placed on the scene in the place of (or, in some cases, in addition to) police. Many of these programs were inspired by Crisis Assistance Helping Out On the Streets, known as CAHOOTS, a mental health crisis response initiative founded in Eugene, Oregon, in 1989. The “clubhouse” approach has similarly taken hold—the oldest and largest, a New York nonprofit called Fountain House, serves about 2,500 people, many of whom have previously cycled through involuntary treatment. And peer-led “living room” and respite centers, which focus on de-escalating individuals in periods of crisis to prevent hospitalization, have become popular areas of investment in other cities.
While some of these programs, like Fountain House, have leveraged their success into securing more municipal investment, many others have struggled to stay afloat as their government funding has plateaued or shrunk. The mental health care system’s patchwork nature and reliance on nonprofits has hobbled many crisis response programs in particular. In May, an audit by New York City Comptroller Brad Lander found that more than one-third of eligible mental health calls failed to be routed to the city’s four-year-old crisis response pilot program, B-HEARD, for reasons unknown. In Chicago, crisis responses from the Crisis Assistance Response & Engagement, or CARE, pilot program—already restricted to certain neighborhoods and limited hours—fell by about 64 percent in 2024, and the pilot’s federal funding is now running out. In Eugene, CAHOOTS ended operations earlier this year after White Bird Clinic, the nonprofit contracted to operate the program with only 40 percent of its costs covered by the city, was forced to make substantial cuts.
Given these numbers, it’s all too easy to dismiss how effective these programs can be when they are properly funded and operated. These approaches have been found to de-escalate crises and, in many cases, encourage people to seek mental health treatment voluntarily. Chicago CARE clinician Drake Schoeppl described to the Chicago Sun-Times in June how he once de-escalated a situation in which police had surrounded the home of a distressed woman who had barricaded herself inside, eventually convincing her to go to the hospital voluntarily. Similar outcomes are achieved every day. But without a robust, transformative social safety net built up around them, these programs face an uphill battle from the start—as one White Bird employee told The Atlantic in 2020, “Where are you going to bring someone if not to the hospital or jail?”
The expansion of involuntary treatment often shifts funding away from already struggling programs, with little progress to show for it. Two years after its implementation, Newsom’s CARE Court initiative has failed to deliver on its promises in California, executing only 528 treatment plans and a dismal rate of completion. Still, Orange County Health Care Agency Director Veronica Kelley Voice told Voice of OC in July that as a result of having to staff CARE Court, “there are a lot of other programs that do great work that I have to cut.” In a statement to The Progressive, Kelley’s office said that the affected programs provided services related to employment, transportation, and peer support, which “help clients become more self-sufficient, which in turn enhances their overall well-being.”
Proponents of involuntary treatment expansion, including Cuomo and Adams, are careful to note that civil commitment should only serve as a “last resort.” Absent substantial efforts to meet the demand for non-emergency mental health care and related services, however, the supposed last resort has become the first resort. City and state officials who pursue investments in mental health care alongside involuntary treatment expansion are often seen as pragmatists willing to face uncomfortable truths. But their dual strategy serves an important political function: It sets a precedent that no one should expect more funding for mental health services unless they are willing to accept the degradation of civil liberties, as well.
By effectively sabotaging evidenced-based mental health care alternatives, our elected officials have presented voters with a false choice between carceral solutions and no solutions at all. And by framing coercion as a necessary prerequisite to providing mentally ill people with housing and other forms of material support, proponents of involuntary treatment can dismiss their critics as naive or even indifferent to the suffering of the mentally ill and unhoused, as if we’d just as well do nothing to address the crisis. In the funhouse mirror of public discourse, care and coercion have become impossible to disentangle—as anti-involuntary treatment advocates Stefanie Lyn Kaufman-Mthimkulu and Ruth Sangree wrote in The Nation in 2023, “Investing in carceral solutions has stunted our capacity to imagine other systems of care.”
Mamdani’s Department of Community Safety plan will likely face significant obstacles from the get-go. The tax hike from which he hopes to secure some of its funding would depend on cooperation at the state level, where he is almost guaranteed to encounter resistance. But he has already succeeded in pushing back against a status quo that forces unhoused people and people with mental illness into profoundly isolating and destabilizing conditions, then uses their inevitable deterioration as evidence that they are too sick to be offered basic rights of autonomy.
In their bids to be viewed as the adults in the room, Cuomo and Adams dismiss alternative visions of mental health policy. What they fail to grasp, as Mamdani seems to, is that reimagining mental health care to center personal autonomy is serious business.