UPDATE: California’s Mental Health Crisis: How We Got Here

Updated May 13, 2024: On Wednesday, thousands of Californians will gather at the State Capitol to speak up in support of our neighbors who suffer from mental heath challenges, and to "disarm the deadly stigma surrounding mental illness." This comes in the midst of a mental health crisis that is overwhelming many of our cities.

We see evidence of this crisis every day. With the passage in March of Prop 1, Californians declared an understanding that the homelessness crisis is largely a mental health crisis, and pledged $6 billion to address it. In this piece, Jon Vankin explains the events that led to the crisis and the roots of the state's efforts to confront it.

Sandra Shells was a 70-year-old nurse at a large Los Angeles hospital, and getting ready to retire, when she was waiting for a bus to take her work early in the  morning of Jan. 13, 2022. She never made it. At around 5 a.m., before the bus could arrive, a 48-year-old man named Kerry Bell punched her in the face, according to the Los Angeles County District Attorney’s Office.

The nurse fell backward to the ground, her head striking the pavement. Three days later, she died of her injuries. The city’s chief of police, Michael Moore, called the brutal attack “a tragic and senseless murder directly tied to the failure of this Nation’s mental health resources.”

The  killing of Sandra Shells was especially horrifying. But it was just one more in a growing trend of crimes connected to mental health problems. In the city of Los Angeles, crimes committed by people with mental health issues have risen dramatically over the past decade. According to Los Angeles Police Department data compiled by the site Crosstown L.A., in 2010 the city saw 152 crimes in which the suspect was experiencing mental illness. In 2018, that number had jumped to 543.

Gov. Gavin Newsom on March 3, 2022, announced a new plan to, he said, bring the problem under control by getting people in California with mental health issues into treatment before they commit crimes, and to stop using jails as de facto mental health facilities. The system proposed by Newsom would be called CARE Court, and would require each of the state’s 58 counties to set up a branch of the court system dedicated to getting people with severe mental illness into treatment—whether they want it or not.

Mental Health, Crime and Homelessness

The official count of homeless individuals in California—a count required by the federal government in order for the state to receive funding—found that of the 161,548 unhoused individuals counted, approximately one of every four is experiencing severe mental illness. California’s homeless population accounts for 28 percent of the nation’s total homeless figure, and the percentage of severe mental illness tracks roughly with the national average.

At the same time, the connection between California mental health issues and criminal behavior seems clear—and has clearly been on the rise. A 2020 report by the consulting firm California Health Policy Strategies concluded that available data “suggests that mental illness in jail or prison is prevalent and that individuals with a mental illness are overrepresented in jail or prison.”

The report found that in 2009, there were about 80,000 inmates in California jails on any given day surveyed, and approximately 15,500 of them had active mental health cases. A decade later the jail population had decreased—but the number of California inmates with mental health problems went up. In 2019, the study found 72,000 inmates and 22,000 mental health cases. That’s a jump over 10 years from 19 percent of inmates displaying mental health problems to 31 percent.

“The jails are where we dump thousands of people who really ought to be in psychiatric hospitals, community-based rehabilitation programs or supportive housing,” wrote the Los Angeles Times in a 2019 editorial. “Those facilities were supposed to be built decades ago to replace state mental institutions, which too often served as abusive warehouses for society’s sick and unwanted.”

The editorial was referring to a process known as “deinstitutionalization,” which, as the name implies, was the ongoing, mass release of patients from mental health institutions. The process began in the 1950s, reducing the California mental health hospital population from 37,000 in 1955 to only 2,500 three decades later.

Where did those psychiatric patients go? And why are such large numbers of Californians with mental health problems either living on the street or behind bars?

The Horrors of Psychiatric Hospitals

The first hospital in the United States dedicated exclusively to patients with mental illness opened before the United States actually existed, in 1773. Located in Williamsburg, Virginia, and known as Eastern Lunatic Asylum—a name later changed to the more palatable Eastern State Hospital—the facility housed as many as 125 patients (called “inmates”) at a time.

The Virginia-based “asylum” did not start a trend, however. It wasn’t until the mid-19th century, thanks to the activism of a Massachusetts schoolteacher named Dorothea Dix, that “asylums” for the mentally ill were constructed in significant numbers. Dix herself was responsible for creating 30 such facilities.

The first state-run mental health hospital in California opened in idyllic Napa Valley in 1875. Indeed, Napa State Hospital (originally called Napa Asylum for the Insane) remains open in 2022—California’s oldest continually operating state hospital. The facility was created initially to accept patients who could not find a place at the nearby, and extremely overcrowded Stockton Asylum, a privately run institution that was the first “insane asylum” in the state, opening in 1851. 

 As California moved toward its peak of 37,000 psychiatric patients in facilities, a series of horrifying media exposés revealed the sordid conditions that existed inside many psychiatric hospitals nationwide. A 1946 Life Magazine report, complete with shocking photos of neglected and abused patients, was especially influential.

California hospitals unfortunately were often as guilty of mistreating patients as facilities anywhere else, with overcrowding growing into a crisis. With accommodations for 600 patients, Napa Hospital’s population swelled to more than 1,300, with individual cabins meant to house no more than 26 stuffed with more than 70 human beings.

What Is Deinstitutionalization?

What to do with the large numbers of mental patients? The answer, supposedly, lay in the burgeoning field of pharmaceutical science. In 1954, the U.S. Food and Drug Administration approved a new medication called chlorpromazine, sold under the brand name Thorazine. The new drug was the first antipsychotic, and it quickly became a favorite of hospital psychiatrists who, until its invention, could treat psychosis and schizophrenia only with dangerous, unreliable procedures such as electroshock and lobotomy.

Lobotomy is a surgery that consists of inserting a sharp implement called a leucotome (lobotomy was also known as “leucotomy”), resembling an ice pick, through the skull and into the brain to disconnect the frontal lobes. Now considered inhumane and largely abandoned as a form of treatment, lobotomy was common in the 1940s and ’50s, and resulted in death for at least one of every 20 patients, and severe, crippling side effects for many more. Amazingly, the creator of the lobotomy, Egas Moniz, won the 1949 Nobel Prize in Medicine for his invention.

Thorazine appeared to accomplish the same therapeutic results for mentally ill patients as those invasive procedures, but more effectively, with less risk. The relatively inexpensive pill appeared to be such a miracle that within a few years it was used not only to treat hospitalized patients, but as a means to release patients from institutions altogether, allowing them to be treated on their own.

Deinstitutionalization had begun.

The process of releasing patients from psychiatric hospitals into the community—where they can, theoretically, receive more personalized treatment and greater personal freedom—was a nationwide trend. But as with so many changes to American society, California was leading the way.

According to psychiatrist E. Fuller Torrey, founder of the national nonprofit Treatment Advocacy Center, “California became the national leader in aggressively moving patients from state hospitals to nursing homes and board-and-care homes.” The state was the “canary in the coal mine of deinstitutionalization,” Torrey wrote, in a 2013 essay.

A ‘New Frontier’ in Mental Health Treatment

Ronald Reagan is often blamed for emptying the state’s hospitals onto the streets, but by the time he became California’s governor in 1967, the California mental health hospital population had already dropped to 22,000. It kept right on declining during his administration, driven by excitement over Thorazine and other new “tranquilizer” medications, with little thought to the social or personal consequences.

“Tranquilizers became the panacea for the mentally ill,” Charles Schlaifer, an official with the congressionally created Joint Commission on Mental Illness and Health, told The New York Times in 1984. ''The state programs were buying them by the carload, sending the drugged patients back to the community and the psychiatrists never tried to stop this. Local mental health centers were going to be the greatest thing going, but no one wanted to think it through.”

In 1963, President John F. Kennedy made deinstitutionalization federal policy, signing the Community Mental Health Act. The mental health law was part of Kennedy’s “New Frontier” program of social and economic reform coupled with technological innovations such as the space program.

The new law provided $150 million in federal funding over three years to build a network of “community” mental health centers that would take over treatment of mentally ill patients, allowing psychiatric hospitals to be largely emptied out, their patients released into society at large. Kennedy’s vision, and that of the Joint Commission on Mental Illness and Health whose 1961 report formed the basis for law, called for a network of treatment centers that would allow mentally ill people to integrate with their communities, living productive and fulfilling lives to the greatest extent possible.

Kennedy Signs Deinstitutionalization Bill

Caring for the mentally ill was a personal issue for Kennedy. His younger sister, Rosemary, had a lifelong history of mental and behavioral problems. At the age of 23 she was the victim of a botched lobotomy—a procedure ordered by her father, Joe Kennedy Sr., partly because he worried for his troubled daughter’s own safety, but also out of fear that the emotionally unstable young woman would somehow disgrace the family name. He had Rosemary confined to a mental hospital after the disabling procedure, prohibiting anyone in the family from visiting her.

When his son, then-Senator Jack Kennedy, secretly visited his sister in 1958, he saw the extent of what had been done to her, and resolved to take action to help the mentally ill.

JFK signed the Community Mental Health Act on Oct. 31, 1963. Sadly, both for Kenendy himself and for Americans experiencing mental illness everywhere, it would be the last bill he would sign in his lifetime. About three weeks later, Kennedy was gunned down in Dallas, Texas, bringing an end to the New Frontier.

With Kennedy’s death, enthusiasm for funding the national network of mental health treatment centers dried up. Only about half of the planned centers were ever constructed. None received full funding and no further laws to keep the centers operational were passed. And yet, patients continued to pour out of psychiatric hospitals.

The passage of the federal health insurance programs Medicare and Medicaid in 1965, under President Lyndon Johnson, further accelerated deinstitutionalization. Medicaid, which provides health coverage to low-income Americans, specifically excluded in-patient psychiatric hospital care from its roster of covered treatments. As a result, states went all-out to collect Medicaid reimbursement cash, taking mentally ill patients out of psychiatric hospitals and placing them into nursing homes where almost half of the costs were covered by the government insurance plan. By 1980, according to the Kaiser Family Foundation, 44 percent of all nursing home patients in the U.S.—750,000 patients—were considered to have serious mental illnesses.

Edmund G. “Pat” Brown, the California governor who oversaw the beginning phases of large-scale deinstitutionalization in the early 1960s, later came to regret the mass social experiment.

“They’ve gone far, too far, in letting people out,” Brown told The New York Times in 1984.

Can People Be Required to Get Help?

People with severe mental illnesses may be compelled to get treatment. The practice of involuntary commitment to psychiatric hospitals has been around as long as psychiatric hospitals themselves. Today, every state has specific laws governing how and when individuals may be forced to get mental health care on either an inpatient or outpatient basis.

In California, however, it’s not an easy thing to do. The reasons date back to the era of rapid deinstitutionalization, when the legislature passed and Reagan signed the landmark Lanterman-Petris-Short Act (LPS) of 1967. Named for Republican assemblymember Frank D. Lanterman and Democratic state senators Nicholas C. Petris and Alan Short, the intent of the LPS Act was to end involuntary and never-ending commitments of people with mental health issues.

The law was designed to close down the practice of confining people to psychiatric hospitals without their consent. The law sets strict criteria for what it calls “5150 Holds”referencing the section number of the California Welfare and Institutions Code that allows the holds. Those involuntary confinements are limited to 72 hours. If the person requires additional care, a psychiatrist can order a “5250,” which permits an additional 14 days.

The holds require a court to determine that an individual poses a verifiable danger to themselves or other people. Those criteria can be met if a person has, for example, attempted or made serious threats of suicide or harm toward others. Finally, those deemed to be “gravely disabled,” unable to feed or clothe themselves (for example), could also qualify for a “5150.”

The LPS law has been modified over the years. Most importantly, in 2002 the legislature passed Laura’s Law, which allows county authorities to compel people into treatment if those individuals have serious mental illnesses that make them dangerous. The law was specifically designed for patients with a condition known as anosognosia, which basically means the inability of mentally ill people to perceive their own mental illness. People with the condition are likely to refuse voluntary treatment because they can’t see anything wrong with themselves.

That was the case with Scott Thorpe, who had a lengthy history of mental illness that caused him to hold seriously delusional beliefs. Thorpe was convinced that the FBI had planted a microchip in his brain, and that he was destined to have a shootout with the FBI agents supposedly tracking him through the chip. In 2001 he went on a shooting rampage in Nevada City. He killed three people and wounded two others. Among the dead was 19-year-old Laura Wilcox, a college sophomore who was filling in at the front desk of a local mental health clinic during her winter break when Thorpe opened fire. 

Wilcox’s parents became national advocates for legislation to allow mandatory treatment orders for people with dangerous mental illnesses. In California, however, the legislature allowed the law to be adopted on a county-by-county basis. As of December 2021, 27 of California’s 58 counties, including Santa Cruz and Monterey, have declined to put Laura’s Law into effect.

Newsom’s CARE Court plan would expand on the existing California mental health laws for forced treatment, setting up a new system of courts for that one purpose only. Unlike under Laura’s Law, counties would be required to put the system into effect, or face penalties from the state. The treatment options under the system would not only include medical care, but housing and other support services—an approach Newsom says “creates a space for a different conversation than we’ve had in the past.”