Skip to content

Unmade Beds

Rethinking the mental health system amid a shortage of psychiatric beds

First came the storm and then came the plague, but South Beach Psychiatric Center isn’t in the business of taking messages from God. If they were, perhaps they would have shut down for good after Hurricane Sandy destroyed parts of the Staten Island complex in 2012, causing a lengthy closure. Or when, just as the revamped center was about to reopen in 2020, the Covid-19 pandemic hit New York, and South Beach had to be hastily rejigged as an emergency field hospital. Across the state, roughly 1,050 psychiatric beds went “offline” in the battle to contain the pandemic; three years later, around 650 remain in the void.

After the rollout of Covid vaccines in 2021, South Beach was finally ready to serve its original purpose. To celebrate, the hospital released a virtual tour of the facilities. The video touts the center’s wide hallways (“less confinement”), high ceilings (praised bluntly for their lower “ligature risk”), and a basketball court hugged by a tall, mesh fence; according to a voiceover, it all has a “non-institutional feel.” At the official ribbon-cutting in October 2021, state senator Diane Savino championed the hospital’s new architectural charm: “Now think about how different it’s going to be for people who are in mental health crisis struggling with issues and their family to see how beautiful this place is.”

Some might argue that the site will forever be ugly and should have been shut down for cruelty alone, never mind all the divine intervention. In the 1970s and 1980s, several people died there as a result of abuse or neglect. Some of these deaths are highlighted in the 1983 documentary Children of Darkness: Anthony Ruggeri in 1979 and Judith Singer in 1980, who were both tied down in straitjackets, held in seclusion rooms, and given high doses of psychotropic drugs. Another patient, Andrew Zamora, died not long afterwards, having been restrained when staff thought he was faking a bad reaction to a drug. Even as recently as 2010, twenty-seven-year-old Jawara Henry, who was autistic, died from suffocation at South Beach while staff members tried to restrain him.

Mental health advocates have always run into a contradiction when it comes to inpatient psychiatric wards. In addition to sometimes providing poor or even dangerous care, psychiatric wards can represent an extension of the criminal justice system, punishing people who deviate from societal norms, especially in cases of compulsory treatment. On the other hand, as the lack of community services following the widespread closure of asylums in the late sixties and early seventies made clear, the alternative to hospitalization can be just as harrowing: long-term prison sentences, homelessness, death.

New York is now at a critical juncture when it comes to dealing with this issue. Some hospitals don’t want to bring back the psychiatric beds that were lost during the pandemic, which can be a drain on insurance and potential Medicaid reimbursements (surgical and general medical beds typically bring in more money). Advocates are split: for some, the beds need to return, and double that number while you’re at it; for others, the shortage is a radical chance to reconsider how we care for those in acute stages of psychiatric crisis. Complicating this debate is an ongoing, nationwide crime panic: politicians across the country have been tightening their grip on forced treatment policies amid an increase in fearmongering about people with mental illness being violent.

Care Not Cops

In January of this year, New York governor Kathy Hochul urged hospitals to reinstate the psychiatric beds they had taken offline, proposing a fine of $2,000 per day for stragglers who had not complied by April. “While Covid-19 and other public health threats remain present across New York, hospitals must continue their efforts to return to their duly licensed operations,” said a memo from her administration. This was not her first resort. Last year, the governor tried to speed up the slow return by adding a $27.5 million investment for qualifying Medicaid psychiatric beds, representing a 20 percent increase in payouts for hospitals. As of November 2022, however, federal funding for this carrot had still not been approved.

For some, the beds need to return; for others, the shortage is a radical chance to reconsider how we care for those in acute stages of psychiatric crisis.

There is a broad swath of hospitals where psychiatric beds went offline during the pandemic. Northwell Health’s Syosset Hospital reconfigured twenty of its beds; according to a spokeswoman, these beds are still unavailable, but “Northwell has the appropriate capacity to meet the inpatient mental health needs” of the communities they serve, and they are “currently studying a number of options on how best to return those beds to service.” New York Presbyterian’s Allen Hospital got rid of its thirty-bed psychiatric wing—perhaps not a coincidence, given a 2017 proposal to shut it down and expand the hospital’s spine center and maternity ward instead. [*] (NYP did not respond to multiple requests for comment.) Forty-nine beds were lost at the Brooklyn Methodist Hospital; according to recent reporting by Politico, twenty-four of those beds were restored last summer, but the remaining twenty-five require further planning. New York City Health + Hospitals reportedly turned over 382 behavioral health beds to Covid-19 patients, two hundred of which remain offline, according to a rep who said that the beds will return by December, as “staffing remains the biggest challenge”—a problem they are combatting with recruitment campaigns and student loan repayment offers. Westchester Medical Center Health Network closed forty psychiatric and twenty drug recovery beds in Kingston at the Mary’s Avenue Campus to much protest. In May 2022, WMCHealth agreed to return twenty inpatient beds; the network said in an email that the targeted return date was by the end of this year, and that they will also increase psychiatric beds at the MidHudson Region Hospital in Poughkeepsie from forty to sixty.

Even as the state struggles with a net loss of psychiatric beds since the pandemic began, new policies are being designed to funnel more and more people toward inpatient psychiatric care. Last November, New York City mayor Eric Adams released a directive giving police officers and medical workers the ability to force anyone who appears to be mentally unwell into a psychiatric evaluation. Recent reporting from the NYPD regarding the early days of this directive indicates the policy hasn’t yet led to a big uptick in ER presentations, but anecdotally, some emergency workers have seen a shift, and there is a lack of data about how often the mere threat of a forced evaluation has been used.

Anthony Almojera, a New York Emergency Medical Technician with his own experience of suicidal ideation, says that police try “to not deal with EDPs if they don’t have to. Notwithstanding this mayoral directive.” EDP means “Emotionally Disturbed Person”; if someone is classified as EDP-C (critical), that means they have the potential for violence against themselves or others. Thanks to Adams’s new directive, cops can skate over this distinction and make their own uninformed assessments based on nothing but a disheveled look in a public place, which will inevitably have a disproportionate impact on New York’s unhoused population. EMTs were never necessarily the ideal landing pad for these calls, says Almojera, let alone cops, and the city even recognized this at one point, promising to provide trained social workers via an initiative called B-HEARD (Behavioral Health Emergency Assistance Response Division), which launched in June 2021. “It’s an EMT rolling with a social worker to go to the lower acuity EDP calls, the ones that just say, ‘Hey, I’m feeling depressed,’ so the social worker can talk to them and have them stay home, and there’s no police presence,” says Almojera.

B-HEARD is like Oregon’s CAHOOTS (Crisis Assistance Helping Out On The Streets) program, developed over thirty years ago, which provides mental health first responders alongside police. It’s a model that comes up again and again, as police tend to aggravate, not de-escalate, mental health callouts. Take for example, Daniel Prude’s death in Rochester, New York, in 2020. After Prude’s brother called police about his sibling’s erratic state, police placed a mesh hood on him and pushed his face into the pavement. Prude stopped breathing and died a week later in the hospital. Back in 2016, the NYPD shot Deborah Danner in the Bronx while she was holding a baseball bat during a schizophrenic episode. As recently as March, Raul de la Cruz was shot by the NYPD in the Bronx and left in critical condition after his father called 311 to seek medical help for his son. And after this issue went to press, a second man in the Bronx was shot in the midst of a mental health crisis while holding a pair of scissors and a kitchen knife.

Another person who didn’t get the help he needed was twenty-six-year-old Eudes Pierre, who was shot dead by police in December 2021 after he called 911 on himself (unbeknown to police), saying a gentleman was armed with a knife and a gun. Eudes’s cousin Sheina Rose remembers hearing the cops saying “EDP, EDP, EDP” on the video footage of Pierre’s shooting released by Attorney General Letitia James last year. But to his family, Eudes was more than an acronym. “He was always down for a cause,” says Rose, “for people to be themselves and for everyone to be accepted for themselves.” He played basketball, drew comics, rapped, and acted as a brother to the son Rose had when she was young. Before his death, Eudes had started selling coladas, which were especially popular during the annual West Indian Day parade on Brooklyn’s Eastern Parkway. He had big plans to start delivering the drinks and had just created an Instagram page for the budding business. In Rose’s retelling of his death, Eudes raced up the stairs from the subway onto the street, after police tried tasing him; the NYPD claims he ran at them—and so they fired. A pink kitchen knife was found at the scene, but no gun. Eudes’s family is hoping to get rid of the suicide-by-cop defense for police shootings: “We just think that’s so insensitive, so inhumane to talk about Eudes like that, like they did their job.” They also want peers, not police, alongside EMTs and social workers as part of mental health crisis response: “people who experience mental health, maybe psychosis, and all that kind of stuff, that are more equipped and have more emotional intelligence.”

For many, New York’s progress on providing an alternative to police intervention is not moving fast enough. Up until March 26, the B-HEARD teams were operating sixteen hours a day in fifteen precincts, according to a spokesperson for the program. This has since expanded to twenty-five precincts. “FDNY currently has sixty-four individuals operating on B-HEARD,” the rep says, with an additional twenty-seven from NYC Health + Hospitals. According to the program’s own data reports, in the first three months of 2022, the teams only responded to 16 percent of 911 mental health calls in the relevant catchment areas. “It’s not enough,” says Almojera. “It’s supposed to run twenty-four hours a day, seven days a week, but it’s not because we’re short staffed throughout the whole system.” He continues: “Right now, on my little piece of screen of the area I’m working I have one, two, three, four EDP calls holding, and I only work this little section of Brooklyn. There’s no mental health unit here, there’s no B-HEARD unit here. So, the crew is regular ambulances going to these calls.”

As acute as the current lack of psychiatric beds is, the problems with New York’s mental health system begin much earlier in the pipeline that eventually leads people to inpatient care—that is, if they get there.

Force the Issue

In Albany’s Egg Auditorium, which is shaped exactly how it sounds, a woman named Lisa walked to a pile of premade signs and picked out a bright pink one: “This is the one for me.” The sign’s message, “treatment not jail,” resonated; she has spent time in jail for “conspiracy to burglarize” due to mental illness. Nowadays, Lisa and her friends play card games—preferably Spades—“to ease our minds” at the Empowerment Academy in Buffalo. The Academy, part of the Buffalo Restoration Society, helps people get into and, more importantly, out of the mental health system by offering support like legal services and food pantries.

For many, New York’s progress on providing an alternative to police intervention is not moving fast enough.

Lisa and I were at the Egg on a Monday in mid-March as part of the New York Association of Psychiatric Rehabilitation Services (NYAPRS) twenty-sixth annual Legislative Day: a daylong lobbying session. NYAPRS is a coalition of people who use and provide recovery-based mental health services. Around 250 people with experience of serious mental illness, addiction, and homelessness traveled in from across the state to press for, among other things, an increased cost-of-living adjustment for mental health staff and new peer crisis respite programs.

Earlier in the morning, speakers fired up the crowd—“You’re going to ask for sixteen million to build out that court system, make sure every corner of New York has a mental health and drug court diversion program in their county!”—and there were pamphlets with talking points for the power brokers in Albany. Last year’s event wasn’t as successful as NYAPRS CEO Harvey Rosenthal had hoped. Flipping through the pamphlet, he lingered on page six, “Don’t Expand Kendra’s Law,” and told the crowd: “You don’t have to really say anything about it because we made that case last year. They did expand it, but they were not willing to expand it again because of people like us!”

Kendra’s Law was created in 1999 to honor thirty-two-year-old journalist Kendra Webdale, who was pushed into the path of an oncoming subway train. The man who pushed her had been in and out of hospitals for schizophrenia. Kendra’s Law, now referred to rather euphemistically as Assisted Outpatient Treatment (AOT), allows caseworkers, family members and even roommates of someone experiencing mental illness to petition for a compulsory outpatient court order. If a person doesn’t comply, they can be evaluated and admitted, depending on their recent psychiatric history. Black people have been almost five times as likely as white people to be subject to an order under Kendra’s Law, according to a 2005 report by New York Lawyers for the Public Interest. Until last year, the criteria to receive an AOT under Kendra’s Law dictated that a person had to have been in and out of the hospital and demonstrating violent behavior. This was amended in 2022, to the horror of civil liberty groups, allowing judges to renew orders within a six-month period if the mental illness “substantially interferes with or limits one or more major life activities.”

California also tightened its compulsory treatment laws last year. Governor Gavin Newsom signed the CARE (Community Assistance, Recovery, and Empowerment) Act in September. The Act targets people deemed a danger to themselves or others, with a laser focus on certain mental illnesses: “CARE Court is NOT for everyone experiencing homelessness or mental illness; rather it focuses on people with schizophrenia spectrum or other psychotic disorders who meet specific criteria,” according to a FAQ booklet. A person suspected of meeting the criteria can be referred to a “CARE Court” by (among others) family members, and first responders, where a judge can then order treatment. Those who refuse can be placed under conservatorship. The Act stipulates that seven counties, including San Francisco and San Diego, will have to establish CARE courts by October 2023, and the remaining fifty-one counties by December 2024. Concurrently, the mayor of San Diego is rallying behind a bill that would loosen the definition of “gravely disabled,” the criteria for involuntary treatment in California, which at present is defined as the inability to clothe, feed, or shelter oneself.

That day at the Egg, after a round of Au Bon Pain catering, we bundled into an elevator downstairs and circled around a long, gray, underground corridor, home to several state government buildings, a barber shop, and a restaurant offering a pizza pie deal. It was thick with state troopers. The security line to get into the state capitol, where a press conference was planned before attendees scattered for meetings with officials, took around an hour. People were sweating in winter coats worn for the impending snowstorm, and those getting chosen at random to be patted down didn’t seem so random.

Among the chanters outside the Capitol was sixty-two-year-old Rodney Hills, who yelled, “Housing is essential for our mental health!” Hills, who’s from Buffalo, has spent time in and out of psychiatric centers since he was a child and still remembers the people who helped him as a kid. But he also has less fond memories of the system. On a recent voluntary visit to a Buffalo inpatient unit, the hospital staff tried to force him to stay longer than he wanted to after he complained about how he was being treated, he says. Being forced to go to an inpatient unit, or, even more confusingly, being forced to stay after choosing to go, represents a chipping away of a patient’s autonomy that can have a net negative effect on mental health in the long term. “When you make that choice and they . . . then penalize you for it, they try to punish you,” Hills says, trailing off. “If it wasn’t because of the fact that I knew the law, I’d have been committed, and that would have been it.”

Black people have been almost five times as likely as white people to be subject to an order under Kendra’s Law, according to a 2005 report by New York Lawyers for the Public Interest.

This was also the case for Ben (not his real name), who was taken to a psychiatric hospital while a student. “I know they were concerned for me, or I frightened them, or I made them feel uncomfortable,” he says of the administrators at his school. They tried to get him to go voluntarily, but as he realized what was happening and left the campus, an ambulance and police car arrived to take him to a nearby ER.

The psychiatric ER was an uncomfortable experience, Ben says, and the environment focused on mitigating suicide risk didn’t help. “It was this strange state of limbo with these hard, plastic, half bed/half chairs. Comfortable enough to fall asleep in,” he says, “but not to stay asleep. And blankets that covered you but didn’t keep you warm.” Later, he was admitted to a hospital upstate that was nice and clean, with beautiful grounds and a basketball court. Friends visited and brought him spare clothes, and he enjoyed “that hour outside each day, the trees, the wind, the mostly inflated basketballs, the mostly flat court.” But the comfort these amenities provided was limited.

Sometimes, Ben felt the hospital staff were unaware of the power dynamics at play. “At some point, they were doing a little bit of a humor, ‘This is your captain speaking’ type of thing through the intercom, and it just felt very in bad taste,” he says. “One rule of jokes is don’t tell a joke about something that is more serious to your audience than it is to you.” After all, these were the people making him take medication he’d begged not to have. “I’m not an idiot. If I know that if I say no, somebody can hold me down and do it, then is the fact that I go up there and put my arm out any different?” he asks. “I’ve already relinquished bodily autonomy at this point.” Now, part of his journey regaining that autonomy is in dancing.

Force, of course, is a part of life. “If a kid runs out in front of a car, you grab him and you pull him out of the way,” Ben says, “it’s not an experience you’re willing to let them learn from.” At the same time, there are some contexts in which force can do more harm than good, and it’s better to make your own choices: “If you stick your finger in a candle once, you’ll know for the rest of your life it’s hot.” Rodney Hills agrees. He says people should respect a patient’s decision to voluntarily admit themselves: involuntary treatment is “not helpful, simply because of the fact that people need to be spoken to from the human part of themselves, instead of being categorized and not viewed as an individual who has specific needs and issues that are totally different from someone else.” For Rodney, he wants to talk to someone who really listens, and is talking with him, not at him. “I want a person to understand what I’m saying, and know that I know what I’m talking about,” he says, thumping his chest, “that I know me.”

Rosenthal says the Covid political environment has been rough for mental health advocates. “We’ve fought for years,” he says of compulsory treatment, “but last year was a terrible year.” The combination of fresh local elections, subway killings—in particular the very high-profile murder of Michelle Go, whose killer was deemed unfit to stand trial in 2019 after turning himself in and was admitted to a psychiatric hospital instead—and general pandemic fatigue created a frenzy. “There have been subway tragedies in the past, and we’ve not seen this degree of overreaction. There’s something about this climate, people just want immediate answers . . . they are looking for a scapegoat.” He goes on: “We were saying less police, now we’re saying more police. We were saying less hospitals, now we’re saying more hospitals. We were saying more choice, now we’re saying less choice.”

Today, the possibility of being admitted to a psychiatric ward looms over any call for help during a crisis. Almojera, the EMT, tries to encourage people he meets on mental health calls to go to the hospital if needed, but it can be difficult. “They are afraid they are going to get admitted, that they are not going to come out of the hospital. They are afraid there will be a stigma if they go to the hospital for psychiatric issues. They are afraid because they’ve been through the system before, and it doesn’t work, so they sit there and think it’s pointless, get fearful that they are going to just get tossed back out into the street.” Given the current shortage of psychiatric beds, this is often exactly what happens. A lack of capacity for inpatient psychiatric treatment, combined with looser parameters for who can be forced to seek care, is in many ways a worst-case scenario which can lead to over-extended staff and a revolving door of patients who don’t receive the care they need.

Almojera has noticed the directive from Adams playing out in waves—crashing and receding—particularly in the city’s subway system. Hospitals, he says, are discharging patients after twenty-four to forty-eight hours. “They are starting to pull people off the streets, but they are back out. . . . It’s a splashy headline,” he says. “It’s like, ‘oh look I don’t see the homeless guy on the train as much anymore,’ but they are just shifting them around. It’s musical chairs.” There aren’t enough beds: though Hochul has proposed an additional 150 in this year’s budget, Almojera calls her increase of fifty last year “a joke.” But there’s also not enough help of other kinds.

Joy Diversion

As shiny as the new South Beach Psychiatric Center might be, healing also happens in action, not just space. This is an area in which Fountain House, a national nonprofit created by people living with serious mental illness, thrives. Fountain House runs several “clubhouses” in New York, where people can learn new skills and build community. They are places to go but not to stay. Where people can find a support system and are valued as equals. Back in Albany, I talked to a man named Richard who works on a newspaper at the clubhouse in Hell’s Kitchen. “They serve meals for $1.50,” he says. “That’s one of the units you can be in, the culinary unit. People are learning skills as well; a lot have been in institutions for years and don’t get anything out of the institutions.” The clubhouse provides social workers, a community, and the feeling of being heard. “On Thanksgiving, Christmas, there’s always some sort of gathering or party going on for those holidays,” he says, “if you don’t have anywhere to go.” Becoming a member is simple: you can upload a history of serious mental illness or a referral from a doctor on the website. This ease is a salve in a litigious country where it can be hard to find therapists open to clients with a history of hospitalization.

A lack of capacity for inpatient psychiatric treatment, combined with looser parameters for who can be forced to seek care, is in many ways a worst-case scenario which can lead to over-extended staff and a revolving door of patients who don’t receive the care they need.

But sometimes people do need a place to sleep and to be monitored too. One alternative to hospitals is a concept called peer crisis respites. These are comfortable centers—nothing like an emergency room—usually with eight to ten beds, says Rosenthal. They are typically run by nonprofits or charities and staffed by people with experience of mental illness. “It looks like a regular home, very normalizing, calming, good couches, decent food, you can sleep if you want to, you don’t have to go to a program,” says Rosenthal. While peer crisis respites have gained popularity in the past decade, people with mental illness have been looking after each other for a long time. One example is People USA’s Rose Houses, created in 2001. Described on their website as a home-like alternative to psychiatric ERs and inpatient units, the houses are “100 percent operated by peers who have their own personal lived experiences with behavioral health challenges.” In New York, there are a number of these kinds of respites, including four which are operated in partnership with the Health Department. Having peers check in on people can make a huge difference amid the isolation of being hospitalized. “I remember fifteen-minute checks,” says Ben of his time upstate, “standing in the shower, and begrudgingly poking my head out,” but also “feeling deeply alone, crying uncontrollably, and no one there to help me,” he adds.

“The public probably sees the mental health system as maybe too wishy-washy or liberal or ineffective,” Rosenthal says, likening the popularity of conservative attitudes about mental illness to the backlash against bail reform. “People feel like the system is failing, people are suffering. But we often see it as a failure of engagement and follow-up.” As Ben notes, psychiatric hospitals are themselves not rooted in reality, down to patients being denied the ability to complete simple tasks like cutting their nails. “I remember taking the train back home with my freshly cut nails, fingertips soft like a baby,” he says. “Touching things, even dirty things like ticket machines and money.” It was “this surreal sense of being part of the world again.”

In Rosenthal’s telling, the alternatives to the status quo seem achingly simple: instead of hospitals, diversion through crisis respites or stabilization centers. Then after that crisis period, “a person to walk with you back into the community”; housing that will accept you, regardless of drug or mental health history; and finally, a place to spend time, like Fountain House. Others are pushing for advanced directives, where someone can state their preferred treatment plan before a crisis arises.

These are the bright spots and creative ideas circulating about how to more ethically and effectively provide mental health care to people in distress. But for now, state and city governments seem to be careening in the other direction. New York’s psychiatric bed shortage is a legitimate problem, but it’s also very easy for politicians to zero in on: it sounds simple and is easily measured. Even if all of the beds lost during the pandemic are eventually accounted for, the system is broken at several crucial points, from the inability of many to voluntarily access help before they’re in crisis, to who responds to a crisis and how. And even if the rebuilt South Beach Psychiatric Center stays true to the ideal of a healing stay that is presented in its video tour, it will still be a place where some patients are held against their will, a place where, in the past, people were suffocated, trapped in straitjackets, and denied the right to something that would become the center’s focus during its brief time as a Covid hospital: space to breathe.



[*] Correction: A previous version of this story erroneously stated that the 2017 proposal included plans to build a new spine center; according to the Riverdale Press, the plan was to add four new operating rooms to an existing spine center.