I’ve been curious about what led to the closing of mental hospitals. This post includes excerpts from four articles, including the perspectives of a district attorney and a psychiatrist. State and federal legislation as well as a Supreme Court ruling all factor into the current mess.
Chris Coleman wrote a letter to the editor of the Thousand Oaks Acorn titled Reagan didn’t close institutions (3 July 2019).
« In 1980, under Jimmy Carter, the Mental Health Systems Act of 1980 was passed. This bill provided federal grants to local community mental health centers. One year later, the 96th Congress, with a Democratic majority in both houses, repealed the act. Reagan signed the repeal »
« What Reagan did do, as governor of California, was to sign the Lanterman-Petris-Short Act in 1972. That bipartisan legislation made mandatory institutionalization of mental health patients by family members and civil courts illegal. »
« The majority of mental hospitals in California were actually closed in the late 1990s, when [Governor] Pete Wilson formed a task force to examine state hospital operations. The task force found that the populations of many state hospitals had dropped dramatically and the per-capita costs had skyrocketed to $114,000 per year. »
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Jim Shields wrote an article for the Ukiah Daily Journal titled Who closed mental health hospitals in California? Three guesses, it wasn’t Reagan (19 August 2023).
« There is a longstanding belief that when Ronald Reagan was governor in the 1960s, he “closed down” the state’s mental hospitals, thus leading to today’s epic mental health crisis that includes a large component of the mentally ill who wander homeless in our cities and rural areas… He didn’t close a single hospital. »
« Two legislative forces actually determined the fate of mental health care in this state. »
« In 1967, the Lanterman–Petris–Short Act (LPS Act) a so-called “bill of rights” for those with mental health problems passed the Democratic-controlled Assembly 77-1. The Senate approved it by similar margins. Then-Gov. Reagan signed it into law. »
« You could say mental health patients after the law was passed, voted with their feet: They left their rooms and walked out the hospital’s front doors, never to return. »
« It was co-authored by California State Assemblyman Frank Lanterman, a Republican, and California State Senators Nicholas C. Petris and Alan Short, both Democrats. LPS went into full effect on July 1, 1972. »
« Initially, mental health advocates pushed for community-based mental health facilities that would replace the closed mental hospitals. But that never happened because even though post-Reagan the legislature was still controlled by Democrats, no major funding for new community-based mental health facilities ever occurred. And that situation basically is still the case today. »
« The second force at work in the mental health care issue were the courts and what is known as “deinstitutionalization.” During the 1960s, many people began accusing the state mental hospitals of violating the civil rights of patients…. The new law ended the practice of institutionalizing patients against their will. »
« A mental patient could be held for 72 hours only if he or she engaged in an act of serious violence or demonstrated a likelihood of suicide or an inability to provide their own food, shelter or clothing due to mental illness. But 72 hours was rarely enough time to stabilize someone with medication. Only in extreme cases could someone be held another two weeks for evaluation and treatment. »
« As a practical matter, involuntary commitment was no longer a legal option that created a whole new dilemma: How do you make a sick person better who refuses help? By definition a mentally ill person is incapable of making rational decisions concerning their health. »
« The LPS Act emptied out the state’s mental hospitals but resulted in an explosion of homelessness. Legislators never provided enough money for community-based programs to provide treatment and shelter. »
« Lanterman later expressed regret at the way the law was carried out. “I wanted the law to help the mentally ill,” he said. “I never meant for it to prevent those who need care from receiving it.” »
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El Dorado County District Attorney Vern Pierson wrote an article for CalMatters titled Hard truths about deinstitutionalization, then and now (March 10, 2019).
« …two of the most well intended but poorly executed movements in this state’s history.
- The first was the de-institutionalization of the mentally ill starting in the 1960’s. The movement, started in Europe, was supported by President Kennedy and ultimately complicated by a U.S. Supreme Court opinion* and civil liberty concerns over forced treatment.
- The second in recent years was fueled by concerns about perceived mass incarceration, and the reality that our jails and prisons had become the de facto mental facilities. »
*O’Connor v. Donaldson, 422 U.S. 563 (1975)
“PRIMARY HOLDING: If an individual is not posing a danger to self or others and is capable of living without state supervision, the state has no right to commit the individual to a facility against his or her will.”
« Gov. Reagan signed the Lanterman-Petris-Short Act in 1967, all but ending the practice of institutionalizing patients against their will. »
« The consequence became clear quickly. The number of mentally ill people entering the criminal justice system doubled the first year after the Lanterman-Petris-Short Act was enacted. »
« Offenders would commit low level crimes and be incarcerated. Jail or prison for many meant stabilization through regular sleep, food, hopefully no alcohol or drugs, and for some, much needed mental health treatment. Then, they’d be released. Back on the streets, they would decompensate, get arrested again and continue to serve life on the installment plan. »
“Decompensation is a clinical term used to describe a mentally ill individual’s state of mental health when he or she was previously managing the illness well but suffered a downturn at a certain stage. That stage is considered a decompensation or decline in overall condition.”
« The connection between deinstitutionalization and incarceration is all too obvious. In 1978, the prison population was about 25,000, By 2006, it had grown to over 170,000 and 30 percent of the prison population were designated as needing mental health services. »
« In the last several years, California engaged in mental health deinstitutionalization 2.0. This time it was Gov. Brown who pushed for sweeping new laws. Measures approved by the Legislature and voters have drastically changed the legal landscape and reduced prison and jail populations. By the end of his tenure, prison population has fallen by almost a third. »
« As the jails and prisons emptied, homelessness jumped. Unlike the rest of the U.S. where homelessness has been relatively flat, California’s homelessness spiked in 2015. Now, approximately a quarter of all people experiencing homelessness in this country reside in California. »
« And while there are fewer inmates, the prevalence and severity of the mental illness among prisoners has increased. Astonishingly, in just four years, the number of people in California who were deemed incompetent to stand trial has increased by 60 percent, straining courts and state hospitals. »
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Blake Erickson M.D., M.A. wrote an article for the American Journal of Psychiatry titled Deinstitutionalization Through Optimism: The Community Mental Health Act of 1963 (11 June 2021).
« The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963—more commonly known as the Community Mental Health Act (CMHA) »
« In 1963, Congress then passed and President Kennedy signed the CMHA. With the CMHA, Kennedy and Congress sought to decrease the number of institutionalized individuals by incubating self-sufficient and local mental health care centers. »
« An overwhelmingly Democratic Congress (Senate 65% and House 59%) aligned with Kennedy on political and ideological sentiments. The Senate and House of Representatives introduced identical bills that outlined terms of temporary federal financial support for the initial construction and staffing of community mental health centers. Despite financial concerns, illustrated by a Bureau of Budget internal memo that read, “The real question is who is going to finance operating costs once the federal subsidies are ended or indeed if they can be ended”, bipartisan belief existed within both chambers that the CMHA’s vision was a more hopeful and humanistic alternative to institutional care. This belief was rooted in a deep trust in medicine’s promise to eliminate illness… In the end, the Senate (72-1) and House (335-18) wholly approved the CMHA. »
« The CMHA funded 3 years of federal grant payments to the states, totaling $150 million, for the physical construction and initial staffing of 1,500 community mental health centers to provide five essential services: consultation and education for community and professional organizations, inpatient facilities, outpatient clinics, emergency response, and partial hospitalization. »
« Because of construction and long-term funding impediments, states built approximately half of the 1,500 centers outlined in the CMHA. The nationwide state mental hospital census decreased by over 90% by the early 2000s, from a peak of 558,922 in 1955. Individuals with diagnoses of serious mental illness were scattered across the mental health treatment system, with no single organization accepting longitudinal responsibility to address their basic needs. »
« An optimistic federal belief in locally sustained community mental health care in part drove deinstitutionalization. The CMHA and its failings teach us that optimism without infrastructure slows the path to success. »
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Articles of Interest 