SALT LAKE CITY — The three largest providers of mental health care in America are the country’s three largest jails.
Together, California's Los Angeles County Jail, Rikers Island in New York City and Harris County Jail in Texas house nearly 44,000 people, many of whom suffer from mental illnesses including schizophrenia, bipolar disorder and depression.
That's according to Kenneth Rosenberg, practicing psychiatrist and director of “Bedlam,” a documentary that premiered last week at the Sundance Film Festival. The reason many mentally ill individuals end up in jail — or living on the streets or frequenting emergency rooms — is that they can't get access to long-term care, he said.
“Bedlam,” titled after the notorious London psychiatric hospital founded in 1247, follows several men and women who suffer from mental illness as they seek treatment, navigate the criminal justice system and face life on the street. Rosenberg also tells the story of his sister, Merle, who was diagnosed with schizophrenia and subsequently institutionalized when she was 20 years old.
According to the National Institute of Mental Health, about 1 in 25 U.S. adults suffers from a serious mental illness, defined as a disorder that substantially interferes with or limits “major life activities.” In every country, mental health disorders are on the rise and could cost the global economy up to $16 trillion in health care, social welfare and criminal justice costs by 2030, according to a 2018 report published in The Lancet.
“Our tax dollars are being spent on (emergency rooms) and jails because that's where people end up, as opposed to community mental health programs and diversion from jail,” Rosenberg told the Deseret News.
Barry Rose, clinical manager of crisis services for the University of Utah’s Neuropsychiatric Institute, saw the film on Feb. 3 and called it “accurate,” “sad” and “frustrating.” He commended the filmmakers for highlighting a lack of services for the mentally ill.
“Behavioral health issues are as common as any other medical condition that people have, and they should be treated that way,” Rose told the Deseret News. “Someone struggling with severe depression is often treated differently than if it was diabetes or cancer. People tend to make moral judgements about these people, and that needs to change.”
Because of the stigma associated with mental illness, Rosenberg’s family tried to hide his sister’s illness from friends and neighbors, which made things worse, Rosenberg said. Today in his psychiatric practice, Rosenberg says the biggest obstacle he deals with is shame.
But as celebrities like Michael Phelps, Demi Lovato and Kanye West have opened up about their mental health struggles, and as more individuals use social media to share their experiences, that stigma is changing. Still, “Bedlam” shows that as a society, we are not providing effective care for the sickest and neediest citizens.
Care providers, affordable housing advocates, doctors and law enforcement officers all have a role to play in solving the problem. According to Rosenberg, there is a lot of disagreement about solutions, but there is little disagreement that the current approach is working. “The simple solution is for people to care and for there to be advocacy,” he said.
On the street
"Bedlam" follows Todd, a homeless man nearing 50 who has been waiting desperately for years to get into public housing. When he hears about another delay from his case worker, he throws his phone on the ground, unable to control his rage because of his mental illness. When he finally gets to move in to his own apartment, he breaks down in tears of relief and gratitude because he knows he would not have been able to get off the streets on his own.
The film also helps answer the question of why people like Todd end up living on the street in the first place.
In the 1950s, there were roughly 550,000 patients in America’s asylums. In 1963, President John F. Kennedy signed the Community Mental Health Act with the goal of helping those warehoused in institutions move back into their local neighborhoods. Asylums were to be closed and community mental health centers established in their place.
But by the time Rosenberg finished his medical degree in the 1990s, 90 percent of asylum beds were gone, and the number of mentally ill people in jail or living on the streets had ballooned. Some states saw an opportunity to save money by closing expensive state hospitals without reinvesting in community-based care, and many of the proposed centers were never built.
Today, between 20 and 25 percent of homeless people have a serious mental illness, according to Rosenberg. These people are likely to self medicate with drugs like heroin and develop substance abuse problems as well, he said.
“There was nothing wrong with Kennedy’s Community Mental Health Act, but it never materialized,” said Rosenberg. “People were naïve at the time saying they would replace asylums. There are different people who need different types of care.”
Rosenberg said it’s time for Americans to admit we need long-term institutions and community programs that do a better job of filling in the gaps.
"We don't need to go back to the terrible asylums of the '60s, but we need long-term care and that’s the reality," said Rosenberg.
Theresa Nguyen, vice president of policy and programs at Mental Health America, said many people were neglected and mistreated in the hospital system of the past and that community-based programs that allow a person to work and live at home are often better than extended stays in state hospitals.
“We should strive to keep people close to those systems that are best for long-term recovery, which means opportunities to be connected, not isolated,” Nguyen said.
According to Rose, the problem with current public resources is that there is not enough to meet the need, and people who want treatment have to wait a long time. It is not the case that people with serious mental illnesses are not responsive to treatment, it’s that most people don’t have access to those treatments that are effective, he said.
“Mental health problems are exacerbated by issues like trauma, stress, and poverty. If someone is responsive on meds but has childhood trauma and is low income, these are factors that complicate recovery,” said Nguyen. “Poverty and underemployment are harder to solve than mental illness.”
In the emergency room
In a review of “Bedlam” published on Black Girl Nerds, an online community that supports women of color, Sezín Koehler wrote that it was painful to watch how mentally ill people were treated in the movie and she had to take a number of breaks while viewing.
“It was hard but worth it,” wrote Koehler. “We need to stop looking away from people with mental illness. Their stories deserve witnessing. Their bravery, their survival deserves witnessing.”
Some of the most dramatic scenes in the film take place in the Los Angeles County Psychiatric Emergency Room, where patients who are acting erratically or threatening staff have to be locked in rooms or tied down on tables in order to be treated. Doctors in the film are visibly drained from the work and express frustration that they are only able to provide short-term help for these individuals.
One of the Los Angeles doctors featured in the film, Dr. Dias (whose first name is not shared in the film), says, “If people give up on their family members, if people give up on themselves through suicide, what makes you think society won’t give up?”
Patients in crisis check themselves in to the ER or are brought there by family members or law enforcement. In most cases, patients are released once they become stable. But because of the complexity of psychiatric conditions, it often takes time to determine which medications will work for an individual long-term. While ER staff can help connect patients to community services, those services may be insufficient to meet the individual's needs, and there may be waiting lists.
According to Rose, commitment laws allow hospitals to keep individuals in treatment when if they are not capable of caring for themselves. But in Utah, for example, the commitment law “has no teeth,” Rose said.
“Someone can leave the hospital or drop out of treatment and nothing happens,” said Rose. “There is not much effort to find people not following through with treatment and return them to restricted environment or incentivize them to stay in treatment.”
Those who need long-term treatment the most have the hardest time staying in services and often end up homeless, he added.
Patrisse Cullors, founder of Black Lives Matter, appears in “Bedlam” with her brother, Monte, who is first shown in the ER suffering from a manic episode.
Monte was in and out of juvenile hall for misdemeanors throughout his teen years, starting at age 14.
“He is 38 now, and he has been locked up half of his life,” said Cullors.
Approximately 1.2 million individuals incarcerated in jails and prisons are mentally ill, according to Mental Health America. And 6 out of the 10 states with the least access to mental health care also have the highest rates of incarceration.
But jails and prisons don't do the best job of treating mental illness.
A 2014 study by researchers at the University of Texas showed that more than half of people in prison who were medicated for mental health conditions at admission did not receive pharmacotherapy while incarcerated, a pattern which the study attributes to faulty screening methods.
Currently, Monte lives in a boarding care facility supported by his family. His condition was part of Cullors' motivation to organize Black Lives Matter to campaign against violence and systemic racism towards black people.
“So many of the people who have been killed or hurt by law enforcement have had some sort of mental illness,” said Cullors. Ezell Ford was a 25-year-old black man known to have suffered from depression and schizophrenia who was shot by Los Angeles police in 2014. Charleena Lyles, a 30-year-old black mother of four, was shot by Seattle police in 2017 after she called to report what she thought was someone breaking into her house. She was also known to have suffered from mental health problems, Cullors said.
“This is important to me because I’ve witnessed my family go through hell and back because of a system that has not prioritized us,” said Cullors. “I dread every time my brother goes through an episode, not because the episode is hard but because there are limited resources.”
According to Rose, police are often the first responders when an individual is in crisis, and their expertise in dealing with mental illness is limited. In Salt Lake City, police can call mobile outreach teams made up of mental health specialists who can assist police in these situations, according to Rose.
“But it’s not used 100 percent of the time. It’s a difficult thing for the police to have to try and make those decisions,” Rose said. Mental health courts that link offenders with community-based treatment instead of sentencing them to prison are another excellent tool to help mentally ill people get the help they need instead of being punished for their illness, Rose said.
Admission to Mental health court is based on a screening of the offender's mental health status and a review of the charged offenses. Most mental health courts exclude DUI charges, sex offenses and extremely violent offenses.
“Everyone deserves care, dignity and the chance to live their life whole,” said Cullors.
Rosenberg said the success of programs like these rely on better community understanding of mental illness. He hopes the film will "fuel outrage" and inspire people to respond to everyone with more kindness, he said.
“It’s important to me personally because of my sister,” said Rosenberg. “(Mental health) is among the greatest social crises of our time, if not the greatest. On every level — personal, medical and political — it’s hugely important. What’s fascinating is that there aren’t 30 films at Sundance about this. What’s fascinating is that our film is unparalleled.”