One month prior to the election, President Carter had signed the Mental Health Systems Act, which had proposed to continue the federal community mental health centers program, although with some additional state involvement. Consistent with the report of the Carter Commission, the act also included a provision for federal grants “for projects for the prevention of mental illness and the promotion of positive mental health,” an indication of how little learning had taken place among the Carter Commission members and professionals at NIMH. With President Reagan and the Republicans taking over, the Mental Health Systems Act was discarded before the ink had dried and the CMHC funds were simply block granted to the states. The CMHC program had not only died but been buried as well. An autopsy could have listed the cause of death as naiveté complicated by grandiosity.

President Reagan never understood mental illness. Like Richard Nixon, he was a product of the Southern California culture that associated psychiatry with Communism. Two months after taking office, Reagan was shot by John Hinckley, a young man with untreated schizophrenia. Two years later, Reagan called Dr. Roger Peele, then director of St. Elizabeths Hospital, where Hinckley was being treated, and tried to arrange to meet with Hinckley, so that Reagan could forgive him. Peele tactfully told the president that this was not a good idea. Reagan was also exposed to the consequences of untreated mental illness through the two sons of Roy Miller, his personal tax advisor. Both sons developed schizophrenia; one committed suicide in 1981, and the other killed his mother in 1983. Despite such personal exposure, Reagan never exhibited any interest in the need for research or better treatment for serious mental illness.

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California has traditionally been on the cutting edge of American cultural developments, with Anaheim and Modesto experiencing changes before Atlanta and Moline. This was also true in the exodus of patients from state psychiatric hospitals. Beginning in the late 1950s, California became the national leader in aggressively moving patients from state hospitals to nursing homes and board-and-care homes, known in other states by names such as group homes, boarding homes, adult care homes, family care homes, assisted living facilities, community residential facilities, adult foster homes, transitional living facilities, and residential care facilities. Hospital wards closed as the patients left. By the time Ronald Reagan assumed the governorship in 1967, California had already deinstitutionalized more than half of its state hospital patients. That same year, California passed the landmark Lanterman-Petris-Short (LPS) Act, which virtually abolished involuntary hospitalization except in extreme cases. Thus, by the early 1970s California had moved most mentally ill patients out of its state hospitals and, by passing LPS, had made it very difficult to get them back into a hospital if they relapsed and needed additional care. California thus became a canary in the coal mine of deinstitutionalization.

The results were quickly apparent. As early as 1969, a study of California board-and-care homes described them as follows:

These facilities are in most respects like small long-term state hospital wards isolated from the community. One is overcome by the depressing atmosphere. . . . They maximize the state-hospital-like atmosphere. . . . The operator is being paid by the head, rather than being rewarded for rehabilitation efforts for her “guests.”

The study was done by Richard Lamb, a young psychiatrist working for San Mateo County; in the intervening years, he has continued to be the leading American psychiatrist pointing out the failures of deinstitutionalization.

By 1975 board-and-care homes had become big business in California. In Los Angeles alone, there were “approximately 11,000 ex-state-hospital patients living in board-and-care facilities.” Many of these homes were owned by for-profit chains, such as Beverly Enterprises, which owned 38 homes. Many homes were regarded by their owners “solely as a business, squeezing excessive profits out of it at the expense of residents.” Five members of Beverly Enterprises’ board of directors had ties to Governor Reagan; the chairman was vice chairman of a Reagan fundraising dinner, and “four others were either politically active in one or both of the Reagan [gubernatorial] campaigns and/or contributed large or undisclosed sums of money to the campaign.” Financial ties between the governor, who was emptying state hospitals, and business persons who were profiting from the process would also soon become apparent in other states.

Many of the board-and-care homes in California, as elsewhere, were clustered in city areas that were rundown and thus had low rents. In San Jose, for example, approximately 1,800 patients discharged from nearby Agnews State Hospital were placed in homes clustered near the campus of San Jose State University. As early as 1971 the local newspaper decried this “mass invasion of mental patients.” Some patients left their board-and-care homes because of the poor living conditions, whereas others were evicted when the symptoms of their illness recurred because they were not receiving medication, but both scenarios resulted in homelessness. By 1973 the San Jose area was described as having “discharged patients…living in skid row…wandering aimlessly in the streets . . . a ghetto for the mentally ill and mentally retarded.”

Similar communities were becoming visible in other California cities as well as in New York. In Long Beach on Long Island, old motels and hotels were filled with patients discharged from nearly Creedmore and Pilgrim State Hospitals. By 1973, community residents were complaining that their town was becoming a psychiatric ghetto; at the local Catholic church, patients were said to “have urinated on the floor during Mass and eaten the altar flowers.” The Long Beach City Council therefore passed an ordinance requiring patients to take their prescribed medication as a condition for living there. Predictably, the New York Civil Liberties Union immediately challenged the ordinance as being unconstitutional, and it was so ruled. By this time, there were about 5,000 board-and-care homes in New York City, some with as many as 285 beds and with up to 85% of their residents having been discharged from the state hospitals. As one New York psychiatrist summarized the situation: “The chronic mentally ill patient has had his locus of living and care transferred from a single lousy institution to multiple wretched ones.”

California was the first state to witness not only an increase in homelessness associated with deinstitutionalization but also an increase in incarceration and episodes of violence. In 1972 Marc Abramson, another young psychiatrist working for San Mateo County, published a landmark paper entitled “The Criminalization of Mentally Disordered Behavior.” Abramson claimed that because the new LPS statute made it difficult to get patients admitted to a psychiatric hospital, police “regard arrest and booking into jail as a more reliable way of securing involuntary detention of mentally disordered persons.” Abramson quoted a California prison psychiatrist who claimed to be “literally drowning in patients. . . . Many more men are being sent to prison who have serious mental problems.” Abramson’s paper was the first clear description of the increase of mentally ill persons in jails and prisons, an increase that would grow markedly in subsequent years.

By the mid-1970s, studies in some states suggested that about 5% of jail inmates were seriously mentally ill. A study of five California county jails reported that 6.7% of the inmates were psychotic. A study of the Denver County Jail reported that 5% of prisoners had a “functional psychosis.” Such figures contrasted with studies from the 1930s that had reported less than 2% of jail inmates as being seriously mentally ill. In 1973 the jail in Santa Clara County, which included San Jose, “created a special ward…to house just the individuals who have such a mental condition”; this was apparently the first county jail to create a special mental illness unit.

Given the increasing number of seriously mentally ill individuals living in the community in California by the mid-1970s, it is not surprising to find that they were impacting the tasks of police officers. A study of 301 patients discharged from Napa State Hospital between 1972 and 1975 found that 41% of them had been arrested. According to the study, “patients who entered the hospital without a criminal record were subsequently arrested about three times as often as the average citizen.” Significantly, the majority of these patients had received no aftercare following their hospital discharge. By this time, police in other states were also beginning to feel the burden of the discharged, but often untreated, mentally ill individuals. In suburban Philadelphia, for example, “mental-illness-related incidents increased 227.6% from 1975 to 1979, whereas felonies increased only 5.6%.”

Of all the omens of deinstitutionalization’s failure on exhibit in 1970s California, the most frightening were homicides and other episodes of violence committed by mentally ill individuals who were not being treated.

1970: John Frazier, responding to the voice of God, killed a prominent surgeon and his wife, two young sons, and secretary. Frazier’s mother and wife had sought unsuccessfully to have him hospitalized.
1972: Herbert Mullin, responding to auditory hallucinations, killed 13 people over 3 months. He had been hospitalized three times but released without further treatment.
1973: Charles Soper killed his wife, three children, and himself 2 weeks after having been discharged from a state hospital.
1973: Edmund Kemper killed his mother and her friend and was charged with killing six others. Eight years earlier, he had killed his grandparents because “he tired of their company,” but at age 21 years had been released from the state hospital without further treatment.
1977: Edward Allaway, believing that people were trying to hurt him, killed seven people at Cal State Fullerton. Five years earlier, he had been hospitalized for paranoid schizophrenia but released without further treatment.

Such homicides were widely publicized. Many people perceived the tragedies as being linked to California’s efforts to shut its state hospitals and to the new LPS law, which made involuntary treatment virtually impossible. The foreman of the jury that convicted Herbert Mullin of the murders for which he was charged reflected the sentiments of many when he publicly stated:

I hold the state executive and state legislative offices as responsible for these ten lives as I do the defendant himself—none of this need ever have happened….In recent years, mental hospitals all over this state have been closed down in an economy move by the Reagan administration. Where do you think these . . . patients went after their release? . . . The closing of our mental hospitals is, in my opinion, insanity itself.

In response to queries about the homicides, the California Department of Mental Health had its deputy director, Dr. Andrew Robertson, testify before a state legislative inquiry in 1973. His testimony must rank among the all-time least successful attempts by a public official to reassure the public:

It [LPS] has exposed us as a society to some dangerous people; no need to argue about that. People whom we have released have gone out and killed other people, maimed other people, destroyed property; they have done many things of an evil nature without their ability to stop and many of them have immediately thereafter killed themselves. That sounds bad, but let’s qualify it. . . . the odds are still in society’s favor, even if it doesn’t make patients innocent or the guy who is hurt or killed feel any better.

1980s: THE PROBLEMS BECOME NATIONAL

Until the 1980s, most people in the United States were unaware that the deinstitutionalization of patients from state mental hospitals was going terribly wrong. Some were aware that homicides and other untoward things were happening in California, but such things were to be expected, because it was, after all, California. President Carter’s Commission on Mental Health issued its 1978 report and recommended doing more of the same things—more CMHCs, more prevention of mental illness, and more federal spending. The report gave no indication of a pending crisis. The majority of patients who had been discharged from state hospitals in the 1960s and 1970s had gone to their own homes, nursing homes, or board-and-care homes; they were, therefore, out of sight and out of mind.

In the 1980s, this all changed. Deinstitutionalization became, for the first time, a topic of national concern. The beginning of the discussion was heralded by a 1981 editorial in the New York Times that labeled deinstitutionalization “a cruel embarrassment, a reform gone terribly wrong.” Three years later, the paper added: “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure.” During the following decade, there were increasing concerns publicly expressed about mentally ill individuals in nursing homes, board-and-care homes, and jails and prisons. There were also periodic headlines announcing additional high-profile homicides committed by individuals who were clearly psychotic. But the one issue that took center stage in the 1980s, and directed public attention to deinstitutionalization, was the problem of mentally ill homeless persons.

During the 1980s, an additional 40,000 beds in state mental hospitals were shut down. The patients being sent to community facilities were no longer those who were moderately well-functioning or elderly; rather, they included the more difficult, chronic patients from the hospitals’ back wards. These patients were often younger than patients previously discharged, less likely to respond to medication, and less likely to be aware of their need for medication. In 1988 the National Institute of Mental Health (NIMH) issued estimates of where patients with chronic mental illness were living. Approximately 120,000 were said to be still hospitalized; 381,000 were in nursing homes; between 175,000 and 300,000 were living in board-and-care homes; and between 125,000 and 300,000 were thought to be homeless. These broad estimates for those living in board-and-care homes and on the streets suggested that neither NIMH nor anyone else really knew how many there were.