Sarah Holder is a staff writer at CityLab covering local policy, housing, labor, and technology.
The new PBS documentary connects the de-institutionalization movement that emptied postwar psychiatric hospitals with the surge of homelessness in U.S. cities.
Todd slams his phone on the ground, cracks it in pieces, then picks it up and throws it again. Frustration pours out of him like flames.
Todd has HIV, and a long history of depression and manic symptoms; after a stint at the L.A. County Hospital a year earlier, he’s been living on the streets of Los Angeles. He’s been promised an apartment of his own, a months-long process arranged by a case worker. But there’s a new snag: He’s just been told that he’ll “hopefully” be able to get the keys within a few days. They were just waiting for the current owners of the unit to finalize the move.
“It makes no sense to me,” he yells. “You have somebody sleeping on the goddamn sidewalk when he’s got a f---ing apartment?” Later, more troubles: Todd is charged with a minor offense and loses his housing after a three-month jail sentence.
Todd is one of the estimated 350,000 people in the U.S. with severe mental illness who are also experiencing homelessness, 20,000 of whom can be found in Los Angeles. His story, and others like his, form the backbone of psychiatrist and filmmaker Kenneth Rosenberg’s new documentary Bedlam, which tracks the rise and fall of mental health institutions in the U.S. and the subsequent criminalization of the country’s most vulnerable.
The film, which premiered on PBS this week as part of the network’s Independent Lens series and is streaming online until May 12, is based on Rosenberg’s book, also called Bedlam; both projects were drawn from seven years of research and reporting in L.A.’s hospitals, jails, and streets. The titles come from the nickname of Bethlem Royal Hospital, a pioneering — and notorious — London asylum that opened in 1403. Today, the word is synonymous with uproar and confusion, and asylums are gone. Insead, the largest facilities to house the mentally ill in the U.S. are urban jails: Los Angeles’ Twin Towers, Chicago’s Cook County Jail and New York’s Riker’s Island.
Rosenberg has personal stakes in this history. His sister Merle struggled with schizophrenia for three decades, while their parents struggled to confront and accept her illness. Rosenberg, who was in charge of Merle’s care after his parents passed, found her dead in her bedroom at the age of 55. Her illness led him to become a psychiatrist; the failures of the profession, and the lack of progress made in managing cases like hers, inspired him to make the film.
“We can’t fix something that we can’t face,” Rosenberg says.
To chronicle those failures, Rosenberg guides viewers through the history of the U.S.’s mental illness treatment. Like another troubled American institution — public housing, the subject of this recent PBS documentary — the story begins with a well-meaning plan to build government-funded shelter for vulnerable populations. What follows is disinvestment, decline, demolition and denial.
In the 1950s, more than half a million American patients were held in a vast network of psychiatric hospitals. They provided necessary mental health care, Rosenberg says, but the conditions were inhumane; shutting down these “human warehouses” became a goal of the postwar era. John F. Kennedy, who took office in 1961, provided another push for reform — his sister, Rosemary Kennedy, was lobotomized for what we’d now call bipolar disorder and schizophrenia and lived the remainder of her life in a mental institution. Soon before his assassination, Kennedy signed an act to open hundreds of federally funded community health facilities, meant as preventive alternatives to hospitalization. But when Ronald Reagan became president in the 1980s, he tried to push the responsibility back to the states.
“We built asylums and they were pretty dreadful, or they became pretty dreadful,” said Rosenberg. “Then we decided — for good reason — that we wanted to get rid of the asylums. But we didn’t replace them with something better. We just tore them down.”
Over the course of the late 20th century, psychiatric hospitals emptied out about 1.4 million of their patients in a process of de-institutionalization. But most didn’t land on their feet. “What happened is that people weren’t de-institutionalized, they were trans-institutionalized,” said Rosenberg. “They went from one institution to another: from the asylums to the jails, and the streets.”
Many patients Rosenberg follows also find themselves in the L.A. County Hospital, where overworked staff counsel, restrain, and try to treat them. Todd thrashes and lashes out at staff; after 20 years in jail, being bound to a bed in a hospital cell, surrounded by police officers, feels no different, he said.
But after being discharged, relief can be fleeting, even for those who have stable housing. “Unfortunately, once patients leave our hospital, there’s really little we can do,“ says one doctor. “We can’t keep people detained for long periods of time.”
For cities, the fallout of this exodus is clear. California, which led the charge in emptying its hospitals of patients, is now afflicted with some of the highest homelessness rates in the country. Not all unhoused people are mentally ill — estimates range from a quarter to more than a third — but those who are struggle to keep up with medication, and have encounters with law enforcement that can escalate.
“The definition of insanity is repeating the same thing over and over and expecting different results,” says an ER psychiatrist identified only as Dr. McGhee, who explains her decision to quit working with mentally ill patients at the L.A. County Hospital. “The way we treat mentally ill in this country is insane.”
Because of these glaring institutional gaps, Rosenberg says that the responsibility of caring for the mentally ill often falls on their families, perhaps more so than for any other disease. And it’s the families in the film that offer the shiniest glimmers of hope, short-lived as they may be.
Patrisse Cullors, who’s known as one of the co-founders of Black Lives Matter movement, helps care for her brother, Monte. He’s sweet and sensitive — “I just want to live and be happy and just be left alone,” he says in the film — but Cullors fears that Monte will be hurt by police during a manic episode.
Racial discrimination compounds the endless jail-to-streets merry-go-round. When two people display the same symptoms of schizophrenia or bipolar disorder, “the person of color gets a worse diagnosis, a worse prognosis, and a worse disposition,” says Rosenberg. “Meaning they go to jail instead of a hospital.”
One month after Cullors helps lead the charge to replace a men’s jail in L.A. with a mental health hospital, Monte stops taking his medicine, and turns psychotic; after a stint in a private hospital, he’s discharged; after another psychotic break, he’s on the streets.
“The movement continues, but the reality really sucks,” said Rosenberg.
The book and film were completed before the coronavirus crisis arrived, but Rosenberg says that the pandemic stands to have serious long-term mental health impacts — he fears that the isolation and anxiety will open people up to problems that may have laid dormant otherwise. But the crisis may also underline the importance of preventative public health care.
“You realize now more than ever that health of the entire world affects our own personal health — that’s true with mental illness as well,” he said. “If we have a segment of our society that we abandon, it hurts us economically and socially and psychologically.”