According to the latest federal data, almost half of all unsheltered people in the United States live in California. This is a tragedy—and a travesty: California is also home to the nation’s highest number of billionaires.
The presence of so many people on the streets, many of them appearing understandably miserable, has become perhaps the most contentious political issue in the state. In few places is the sense of crisis sharper than in Los Angeles, home to Bel Air and Beverly Hills, as well as Skid Row, nationally famous for its poverty and high population of unhoused people. Tents have become a common sight all across the city. The number of unhoused people in Los Angeles increased by 9 percent between mid-2022 and mid-2023, with more than 75,000 now experiencing homelessness at any given time. Meanwhile, the mortality rate for those without shelter has risen rapidly over the last few years, with an average of six Angelinos now dying on the streets every single day.
Some of the most popular explanations for the rise in homelessness have avoided contending with the lack of affordable housing (which the most rigorous and comprehensive analyses identify as the most significant cause of homelessness), instead advancing essentially personal diagnoses. According to one recent poll, more Americans blame drug and alcohol addiction and mental illness for homelessness than poverty or the availability of housing. This focus on individual pathology can lead to dangerous policy prescriptions. In his recent run for mayor of Los Angeles (one of the least affordable cities in the country), billionaire Rick Caruso promised to create a municipal department that would “compel people suffering mental illness into care,” in part by amending conservatorship laws to make it easier to institutionalize people living on the streets. Donald Trump too has demanded the return of “mental institutions” in order to “get the homeless off our streets.” Gavin Newsom, the Democratic governor of California, recently muscled through legislation creating so-called CARE courts that, as disability rights and human rights advocates have noted, will make it easier for the state to coerce people into involuntary psychiatric treatment.
Two new books provide much-needed correctives to these violent policies. Sons, Daughters, and Sidewalk Psychotics: Mental Illness and Homelessness in Los Angeles, an academic treatise by sociologist Neil Gong, is an innovative study of mental health care for the poorest and the richest of the city’s inhabitants—showing how the system fails all, albeit in different ways. The Unclaimed: Abandonment and Hope in the City of Angels, a trade book by a pair of sociologists, Pamela Prickett and Stefan Timmermans, poignantly illustrates the forces that leave so many vulnerable to homelessness and addiction as well as to social isolation, excavating the growing population of those who are left to die without a community. Rather than a crisis of mental illness or homelessness or even poverty, these two books argue, we have a crisis of abandonment.
The idea that we owe anything to each other—and that society owes each of us such bare necessities as a home and a basic standard of living—is fast eroding, both of these books suggest. The worlds of the rich and the poor are growing further apart, as those with resources retreat to increasingly fortified sanctuaries to safeguard their status, while those without are left to struggle and ultimately die on their own, with the government intervening mainly to discipline those who fail to render themselves obligingly invisible.
Few authors capture this dynamic as neatly as Gong does in Sons, Daughters, and Sidewalk Psychotics, his study of two strikingly dissimilar mental health treatment regimes in the same city. Even the book’s title exemplifies the growing divide, with “sons and daughters” indicating “both a loving and possibly condescending paternalism,” while the term “sidewalk psychotics,” chosen to be deliberately jarring, sums up the way mainstream society treats its least fortunate.
The book is the product of years of fieldwork. From 2013 to 2015, Gong, an assistant professor at the University of California, San Diego, shadowed caseworkers with the Los Angeles County Department of Mental Health, or DMH, one of many municipal agencies that provide care to mentally ill people experiencing homelessness or housing insecurity. Then, between 2015 and 2017, he turned his attention to the (pseudonymously named) Actualization Clinic, a “private case management program” for wealthy patients in West Los Angeles.
Both programs emerged in what Gong calls the long shadow of the asylum. For much of the twentieth century, the legal and institutional machinery existed for authorities and families to effectively warehouse those with serious mental illness within a constellation of public and private psychiatric facilities, where they might spend years or even decades. By the 1950s, some 600,000 people were confined in public asylums, and horrifying accounts of abuse (think Ken Kesey’s One Flew Over the Cuckoo’s Nest) became common. Such revelations, as well as the proliferation of antipsychotic drugs, a powerful patients’ rights movement, and austerity governance, led to “deinstitutionalization,” or the abolition of asylums in favor of “in-community services.” New laws and court decisions made it much more difficult for authorities or families to institutionalize someone involuntarily for more than a few days. Additional precedents enshrined a right to refuse treatment.
Deinstitutionalization was a major civil rights victory, yet the authorities failed to provide food, shelter, or other forms of care in its aftermath. Within a month of the closure of California’s state hospitals, authorities “began to dump” the patients “on the streets,” a former DMH director told Gong. In the early 1980s, the Reagan administration cut federal funding for community mental health care. Since the authorities lacked the power to permanently confine many mentally ill people, as they had done in decades past, they began instead to scatter them to “less visible, more undesirable areas.” They were, “essentially, left to die, out of sight and out of mind,” Gong writes.
By the 2010s, many of the DMH workers that Gong shadowed felt the best they could do was cajole and coach homeless people to make statements that might allow them to receive benefits. Caseworkers assist people at probation hearings, at the housing authority, and at the Social Security office. They try to get homeless clients into Board and Cares—private, for-profit housing that offers meals and some modicum of support but not true treatment—and then try to appease the private landlords. (Gong recounts seeing one caseworker tell a woman suffering from psychotic symptoms that she should “bang her head on the other wall, the one facing the street,” to avoid angering her new building manager.) It’s “an impossible task,” Gong writes: “managing not only serious mental illness but also the problems of urban poverty.”
Today, many municipal agencies (including DMH) embrace a “Housing First” model—viewing housing as a prerequisite for effective psychiatric or addiction treatment and therefore striving to find lodging for the unhoused—but its efficacy is sharply limited in the absence of other means of social support. Gong found that, although DMH teams often stabilize homeless patients, their interventions—constrained by limited resources, limited powers, and a “limited vision”—rarely seek to reestablish patients’ familial relationships or friendships, foster their passions, or forge for them anything resembling a career. He narrates the story of Jeremiah, a young Jamaican man who ended up on the streets after the onset of psychosis in his late twenties; he was puzzled by his own violence, repeatedly in and out of jail, at risk of imperiling his immigration status. With the assistance of DMH, he secured housing, antipsychotic drugs, and legal support. This is a success story, Gong notes, but Jeremiah still had no access to job training, psychosocial rehabilitation, or individualized therapy. Long-term stability is elusive, perhaps impossible, without investment in the possibility of a full, meaningful life.
The Actualization clinic, occupying a nondescript facility in West L.A. dotted with fruit bowls and flowers, has a notably different project. For the price of about $6,000 a month, its workers endeavor not to find housing for their clients—the cost of an apartment poses no obstacle—but instead to return the mentally ill rich to class respectability: “college, work, healthy social relationships—or, at the very least, an identity beyond that of ‘mental patient.’” Thus, Actualization staff seek to find for their clients an appropriate vocation and instill in them manners of behavior that are unlikely to frighten or startle family or acquaintances. For one patient, Anthony (a middle-aged scion of a wealthy European family), the caseworkers encouraged him to continue to chase his dream—marrying “someone rich and successful,” running a “successful business”—even though they did not view these goals as realistic. “Maybe his ambitions were out of reach,” Gong notes archly, “but striving toward them was a class-appropriate task that made some sense in this milieu.”
Yet whereas DMH workers often expressed frustration at the difficulty of compelling a person suffering serious symptoms into treatment or housing, workers at elite clinics like Actualization make ample use of compulsion. They closely surveil clients, policing even sugar and caffeine use; sometimes workers will “call your family, tell them not to pick you up because you didn’t brush your teeth,” one doctor told Gong. He describes an institution called the “Therapeutic Farm” that demands hours of agricultural and domestic labor, all in the name of treatment. The elite patients, Gong concludes, are “treated but do not feel free,” while the poor patients are “‘free’ but not treated as well.”
In the years he spent with his subjects—sharing meals, marching against street sweeps, sleeping out in encampments—Gong often noticed a “conspicuous” absence: the families of those living on the streets. In The Unclaimed, Prickett and Timmermans—professors at the University of Amsterdam and UCLA, respectively—look squarely at the prevalence of familial abandonment, considering the question of what happens to people who are alone at the end of their lives. They provide the first comprehensive study of “the unclaimed dead”—of people who, because of poverty or estrangement, must be laid to rest by local governments instead of by family. Many of the unclaimed are or have been homeless, contending with addiction and mental illness; many others, though, are simply isolated, discarded, with a roof over their heads but similarly left to expire out of the way. The triumph of The Unclaimed is its refusal to divorce these two phenomena, arguing instead that both emerge from the same society-wide crisis of abandonment.
As the authors note, no federal agency keeps statistics on the unclaimed; cities like Los Angeles, which has multiple agencies that process and dispose of the bodies of the unclaimed, tend to underestimate the total number. By Prickett and Timmermans’s count, well over 100,000 people die unclaimed every year. That figure is increasing. Between 2000 and 2021, for instance, the percentage of people going unclaimed in Maryland doubled, from 2.1 percent to 4.5 percent of deaths.
Prickett and Timmermans narrate the lives of four individuals who went unclaimed in the 2010s, all in Los Angeles. Two of their subjects could have appeared in Gong’s book. Midge came of age in a Catholic orphanage and in the house of a foster family that would send her to bed hungry. As an adult, she struggled with alcoholism and attempted suicide; by her early sixties, she was living in a Dodge passenger van in a church parking lot. The pastor obtained for her a housing voucher, but she turned down the apartment he found after discovering she’d have to give up her cats (and likely her van). Instead, a church family took Midge in, but her health declined and she continued to feel unwanted; she died in 2016.
Another of the book’s subjects, Bobby, was born to a mother struggling with addiction. Raised for much of his childhood by a foster family, he served in the Air Force, got into drugs, spent time in prison and on the streets before ultimately his love of music landed him on America’s Got Talent with a choir organized by his drug treatment center. This brought some measure of renown, as well as sobriety and greater financial stability. But still, Bobby was plagued with chronic pain, and ultimately his health deteriorated to the point that he could no longer perform; he died in 2019.
Prickett and Timmermans’s other subjects struggled not with homelessness or addiction but with social isolation. Lena, the daughter of Mexican immigrants, spent decades on her own. She had barely entered adulthood, in the early 1930s, when a speeding car killed her father; her mother suffered a “mental breakdown” and was institutionalized. Lena married, but her husband died young in 1966, the same year that her brother, a laborer, was crushed to death by a bulldozer. By the early 2000s, she had no plumbing or heat; she passed days in the dark and slept with a hammer beside her pillow. Eventually, a nephew became her conservator (against her wishes) and moved her into a nursing facility; soon, though, family stopped visiting. Lena became, the authors write, “socially dead,” her few remaining social ties torn, her once flush bank account drained by the “cost of growing old in America.” In 2012, she died at the age of 98.
Finally, for David, isolation came with age. For years he had drifted along the countercultural currents of the late twentieth century, moving to Las Vegas in the 1960s, experimenting with drugs, joining Scientology, marrying, divorcing, leaving Scientology, finding a “run-down” apartment he liked in Los Angeles, hiking on nearby trails. By 2017, though, he was in his seventies and had few social ties—his apartment’s property manager suspected he could go days without talking to another person. “David didn’t necessarily feel lonely,” the authors write, “but his social network was small.” In this respect he was like many older people (especially men), perhaps a quarter of whom are considered “socially isolated,” putting them at greater risk of dementia, heart disease, and premature death. David’s world narrowed. “First, his number of friends dwindled, then his body shrank,” Prickett and Timmermans write. He died alone in his apartment. His body was discovered by his building’s super, days later.
Much of The Unclaimed is devoted to the heroic efforts of underfunded, overworked Los Angeles county employees to track down the relatives of the unclaimed, to notify them, transfer an estate, or ask if they would cover the cost of a burial or cremation. For many of the relatives, the expense of a private funeral or the out-of-state transport of remains is too much to bear. Bobby’s son had to take on extra shifts at work and then a loan from his mother to afford a private cremation; Midge’s niece couldn’t claim her aunt’s ashes because she was undergoing chemotherapy and the county didn’t offer shipping. Volunteer organizations have sprung up to bury unclaimed infants and unclaimed veterans with dignity.
What accounts for the growing number of the unclaimed? Certainly, the rising costs of dying in America (just six companies have seized control of 30 percent of the funeral market, the authors comment, driving up prices) contribute to the phenomenon. Yet Prickett and Timmermans note that the likelihood of going unclaimed in Los Angeles has not fluctuated with poverty levels. Further, a great many middle-class and even wealthy individuals are at risk of dying alone and unclaimed. Ultimately, the authors argue that “a common risk factor” is most associated with becoming unclaimed: “social isolation caused by eroding family ties.”
The unclaimed “are not marginal outliers,” they conclude. More than 40 percent of families experience estrangement; some 25 percent of American adults are currently estranged from close family members. Even beyond the bonds of blood, almost 15 percent of American adults live alone, a number twice what it was 50 years ago; among baby boomers, the figure is higher. In a society that is legally structured around the nuclear family unit, this means we are all vulnerable to a life beyond community. Not equally vulnerable, of course, but one of the hallmarks of our atomizing age is the way it drives each of us apart, stealing our time, grinding us down.
“We are at an inflection point,” Prickett and Timmermans write toward the end of The Unclaimed. The holes in the social safety net are getting bigger; the number of people slipping through is growing. Gong too sees the present moment as something akin to a fork in the road. The population of those struggling on the streets is expanding. Calls for punitive police action are increasing. Recent court victories have made it difficult for the cops to simply “sweep” homeless encampments, but a case currently pending before the Supreme Court may reverse this state of affairs. And demands are emanating from across much of the political spectrum to “bring back asylums,” as a Wall Street Journal op-ed put it last year. The New York Times recently noted a “larger ideological shift” in favor of “involuntary treatment.”
This carceral impulse—this desire to sweep away anything that threatens the appearance of order—fundamentally misses the point. The problem of abandonment can only be alleviated by addressing the root causes. Thus, all three authors advocate for greater state support for vulnerable people—a right to housing, say, and universal access to high-quality health care; a true social safety net, a guaranteed standard of life.
Gong, for his part, offers detailed suggestions for improving a range of problems in the current provision of mental health treatment, with both short- and long-term proposals; his conclusion is laudably thorough, though it suffers from treating the return of the asylum as something of an inevitability. Prickett and Timmermans, in keeping with their focus, call for “widening notions of kinship beyond the nuclear family.” Again and again throughout The Unclaimed, they document the myriad ways that the law privileges uninterested relatives over dedicated friends, from the power to make medical decisions for an ailing relative to the right to benefit from the deceased’s estate, to the ability to dictate the manner in which they’re laid to rest. Expanding the range of relationships legitimized by the state—or eliminating the benefits that currently come with legitimation—is an urgent necessity. Further, in America today almost the only free childcare and eldercare comes from overworked blood relations. A redefinition of kindred community must be paired with robust investment in the very organs of community.
Such humane prescriptions feel increasingly rare. Indeed, it is impossible to live in California today without hearing calls for more cages, emanating from across the political spectrum. Gong, Prickett, and Timmermans are right—we are at a crossroads. We can choose to arm our homes, to militarize our public spaces, to lock away those abandoned by society. Or we can choose to address the causes of poverty, isolation, and despair. We cannot choose both.
