Not every mass murder, violent racist attack or even run-of-the-mill street crime can be attributed to mental illness, but a lot of them can. It’s hard to divine whether the crime is driven by mental illness or just that being driven by hatred and mental illness prevents that thing in one’s head that stops a person from acting upon one’s worst feelings. Either way, mental illness plays a significant role in crimes, some horrific and tragic and some banal, except to the victim.

But while we recognize this, it’s become almost impossible to do anything useful about it.

The Rev. Wendy Paige, the pastor for the man charged in the Monsey attack, noted that he had battled with mental illness for two decades and had been diagnosed with schizophrenia. “There hasn’t been anyone who has given a real solution to deal with a grown man who is dealing with schizophrenia, other than ‘Go home and call us if something happens.’” Failing to treat individuals with documented mental health issues is not an acceptable solution.

Years ago, people with severe and chronic mental illness were sent off to delightful places like Willowbrook, subsequently revealed by Geraldo Rivera as a disgusting and abusive institution. And so we closed these places, ended the practice of locking the mentally ill out of sight and forgetting they exist.

Simultaneously, we went to battle for the rights of the mentally ill to live outside of institutions, to live on the street if that was their choice. We fought against forced drugging, leaving them the option of being treated or not, as they were entitled to the same choices of agency as anyone else. Except, as it turned out, many chose poorly. They went off their meds, lost their jobs, ended up on the street and existed as their worse psychotic selves.

Like so many wondrous ideas, there were consequences to letting the severely mentally ill live their own lives, not the least of which was that it had a deleterious impact on other people’s lives, the victims of their actions. It wasn’t good for the mentally ill. It wasn’t good for anyone else. And a great many severely mentally ill people ended up in prison, because we did away with the institutions where they would have been held otherwise.

New York City and the state must work together to treat mental health issues as the serious threat that they are. Both should immediately fund initiatives that enable expedited enrollment in treatment programs so that law enforcement officials and district attorneys can readily access appropriate services in place of, or in tandem with, the criminal justice system, rather than turning these people in need back to the streets.

Aw, that sounds sweet, except it says absolutely nothing. The issue of what to do with the mentally ill is a minefield these days, as one of the many social justice absolutes is that no one can speak to the reality of the problem for fear of stigmatizing people with psychological problems. Of course, there are many degrees of problems, and many people who have issues that can be well-addressed and treated while they otherwise function like anyone else.

That we’ve historically lumped all people with psychological problems into the cuckoo’s nest was another mistake, compelling people who needed and would benefit from therapy or meds to hide their issues rather than seek treatment for an illness like any other illness. But then, it’s not quite like any other illness for people who suffer from severe psychoses. Cancer patients don’t go out on the street in a delusional rage and kill people.

It’s easy for people to call for insipid solutions, like “treat mental health issues as the serious threat that they are.” But what are you going to do about it? Do we cut them loose if they promise to show up to clinics to take their meds, because dangerously psychotic people are so good about keeping promises? Do we build “New Willowbrook” and ship them out of sight, praying this time Nurse Ratched doesn’t neglect them, abuse them or sexually molest them? Do we send them “thoughts and prayers” on the twitters, as if that ever helped anybody with anything ever?

Dealing with the spectrum of mental illness is hard enough if we spoke honestly about the problems, but it’s impossible when we indulge in fantasy acknowledgement of its existence and ignore the fact that there are people who suffer from mental illness who don’t make our hearts hurt, but put bullets or machetes into people’s bodies.

And there are very real legal impediments to addressing the severely mentally ill. As the Monsey attacker “battled with mental illness for two decades,” how did two decades go by and yet here he was, machete in hand? There are psychiatrists and psychologists out there, clinics and private practices, who should have been capable of helping, yet the attack happened anyway. What went so horribly wrong?

We need to find answers, but it’s not nearly enough to say the obvious. The answers may be hard, may present legal issues of custody and agency, may risk stigmatizing mental illness all over again, because the hard reality is that mental illness isn’t as easily quantified and treated with sufficient certainty that a person who, from all appearances, isn’t going to go out and harm someone until he does. And then we start using the same vague and pointless palliative phrases that failed us before and will do nothing the next time.

You want “real solutions”? Then you need to face real problems and talk about them for real. But as long as we can’t speak ill of the crazies for fear that we marginalize them, stigmatize them, hurt their feelings, our prisons will serve as our asylums and when they have a bad day, there’s a good chance someone will be harmed. When that’s all we’re allowed to do, there’s nothing left but to offer “thoughts and prayers” on twitter as people die.