In November 1980, Ronald Reagan, a Republican, achieved a landslide victory against Jimmy Carter in the presidential election. This election also marked a significant shift in the political landscape, with Republicans gaining control of the Senate for the first time since 1954. Although the House of Representatives remained under Democratic control, the Republican influence was considerably stronger due to the support of conservative Democrats.
Just a month before this political upheaval, President Carter had enacted the Mental Health Systems Act. This legislation aimed to continue federal support for community mental health centers, albeit with increased state involvement. Echoing the recommendations of the Carter Commission, the act also proposed federal grants for mental illness prevention and mental health promotion, reflecting a persistent but arguably misguided faith in preventative measures. However, with Reagan’s ascendance to power, the Mental Health Systems Act was swiftly sidelined. The earmarked funds for community mental health centers were converted into block grants to states, effectively dismantling the program. The Community Mental Health Centers (CMHC) initiative, once a beacon of hope, was not just terminated but thoroughly buried, a casualty of political change and differing philosophies on mental health care.
President Reagan’s understanding of mental illness was notably limited, shaped by a Southern Californian perspective that, like Richard Nixon’s, associated psychiatry with Communism. Ironically, just two months into his presidency, Reagan became a victim of gun violence at the hands of John Hinckley Jr., a young man grappling with untreated schizophrenia. Adding another layer of personal exposure, Reagan was also close to the mental health struggles of Roy Miller, his tax advisor, whose two sons both developed schizophrenia, tragically ending in suicide and homicide. Despite these stark personal encounters with the severe consequences of untreated mental illness, Reagan showed little inclination towards supporting research or improved treatments for serious mental health conditions.
The narrative around mental health care during the Reagan era is incomplete without examining California’s pioneering role in deinstitutionalization. Even before Reagan became governor in 1967, California was already leading the nation in discharging patients from state psychiatric hospitals, opting instead for nursing homes and board-and-care facilities. This movement accelerated with the landmark Lanterman-Petris-Short (LPS) Act in 1967, which drastically curtailed involuntary hospitalization, reserving it only for the most extreme cases. By the early 1970s, California had not only emptied its state hospitals but also erected legal barriers making it exceedingly difficult to readmit patients who relapsed. California’s experience served as an early warning sign, a “canary in the coal mine” for the broader deinstitutionalization movement.
The consequences of this shift were almost immediate. By 1969, studies were already depicting California’s board-and-care homes as essentially mini state hospital wards, isolated and depressing, prioritizing profit over rehabilitation. Richard Lamb, a psychiatrist who was among the first to critique deinstitutionalization, highlighted these facilities’ shortcomings. By 1975, board-and-care homes had become a lucrative business in California. In Los Angeles alone, around 11,000 former state hospital patients resided in these facilities. Many were run by for-profit chains like Beverly Enterprises, which had close ties to Governor Reagan. This nexus between the governor’s deinstitutionalization policies and the burgeoning for-profit care industry raised ethical questions about financial incentives influencing mental health policy.
Clustering these board-and-care homes in low-rent, often neglected urban areas exacerbated the problems. In San Jose, for example, the concentration of discharged patients led to community backlash and the emergence of what was termed a “ghetto for the mentally ill.” Poor living conditions and lack of adequate care drove some patients into homelessness, while others were evicted for symptom relapse due to medication neglect. By 1973, San Jose’s streets were becoming a stark illustration of deinstitutionalization’s failures, with discharged patients aimlessly wandering and living in destitution.
Similar patterns emerged across California and in other states like New York. Long Beach, Long Island, saw an influx of discharged patients into motels and hotels, leading to community complaints and the area being labeled a “psychiatric ghetto.” Attempts to mandate medication adherence were quickly struck down by civil liberties advocates, highlighting the legal complexities of managing mental health in community settings. A New York psychiatrist grimly summarized the situation: the locus of care for chronic mentally ill patients had merely shifted from one inadequate institution to many more, equally wretched ones.
California also became the first state to witness a disturbing correlation between deinstitutionalization and increased homelessness, incarceration, and violence. In 1972, psychiatrist Marc Abramson published a seminal paper, “The Criminalization of Mentally Disordered Behavior,” arguing that the restrictive LPS Act led police to increasingly use arrest as a means of involuntary detention for mentally ill individuals. Prisons became de facto mental health facilities, a trend that was rapidly escalating.
By the mid-1970s, studies indicated that approximately 5-7% of jail inmates were seriously mentally ill, a significant rise from the sub-2% figures reported in the 1930s. Santa Clara County jail, encompassing San Jose, established a special ward in 1973 specifically for inmates with mental health conditions, a grim acknowledgment of the growing crisis.
The increasing visibility of seriously mentally ill individuals in Californian communities by the mid-1970s inevitably impacted law enforcement. A study of patients discharged from Napa State Hospital revealed that 41% had been arrested post-discharge, with a significantly higher arrest rate compared to the general population, particularly among those who received no aftercare. This burden was increasingly felt by police departments nationwide. In suburban Philadelphia, mental-illness-related police incidents surged by 227.6% between 1975 and 1979, dwarfing the 5.6% increase in felonies.
Perhaps the most alarming consequence of deinstitutionalization in 1970s California was the rise in homicides and violent acts committed by untreated mentally ill individuals. Cases like John Frazier, Herbert Mullin, Edmund Kemper, and Edward Allaway, among others, became tragically synonymous with the failures of the system. These widely publicized tragedies fueled public fear and prompted harsh criticism of California’s deinstitutionalization policies and the LPS Act. The foreman of Herbert Mullin’s jury directly blamed the Reagan administration’s economy-driven hospital closures for the murders, stating, “The closing of our mental hospitals is, in my opinion, insanity itself.”
Dr. Andrew Robertson, Deputy Director of the California Department of Mental Health, in a 1973 legislative inquiry, offered a chillingly inadequate reassurance, admitting that LPS had exposed society to dangerous individuals who had committed violent acts, but then statistically downplaying the significance, a statement that did little to assuage public concerns.
The 1980s marked a turning point when the localized problems of deinstitutionalization in California became a national crisis. Before this decade, the severity of the situation was largely obscured from national consciousness. President Carter’s 1978 Commission on Mental Health, in its report, failed to acknowledge the unfolding crisis, recommending more of the same policies that had arguably contributed to the problems. The majority of discharged patients remained unseen, residing in private homes, nursing homes, or board-and-care facilities, effectively hidden from public view.
However, the 1980s brought deinstitutionalization into sharp national focus, largely driven by the burgeoning issue of mentally ill homelessness. A 1981 New York Times editorial labeled deinstitutionalization “a cruel embarrassment, a reform gone terribly wrong,” and by 1984, the paper declared the policy “a major failure.” Public concern grew regarding the conditions in nursing homes, board-and-care facilities, and jails, alongside recurring headlines of violent acts by psychotic individuals. Yet, it was the plight of the mentally ill homeless that became the central and most visible manifestation of deinstitutionalization’s catastrophic consequences.
During the 1980s, an additional 40,000 state mental hospital beds were eliminated. The patients discharged were increasingly the more challenging, chronic cases, often younger, less responsive to medication, and lacking insight into their condition. In 1988, NIMH estimated 120,000 patients still hospitalized, 381,000 in nursing homes, 175,000 to 300,000 in board-and-care homes, and a staggering 125,000 to 300,000 homeless. These broad estimates highlighted the lack of precise data and the sheer scale of the crisis.
Abuse and neglect of mentally ill individuals in nursing homes had surfaced in 1974 Senate hearings, revealing practices like bidding for easily manageable patients and exorbitant profits at patient expense. While 1987 legislation aimed to prevent inappropriate admissions to Medicaid-funded nursing homes, follow-up studies indicated minimal impact on actual practices.
Board-and-care homes also continued to be sites of abuse and neglect. Incidents like the discovery of “nine ragged, emaciated adults” in an unlicensed Mississippi facility in 1982, and the 1984 fire in a Worcester, Massachusetts, rooming house that killed seven former patients, underscored the dangerous conditions in many such facilities. Sociologist Andrew Scull described the economics of the industry as incentivizing operators to warehouse residents as cheaply as possible to maximize profit. Furthermore, these homes were often located in high-crime areas, making residents vulnerable to victimization. A 1984 Los Angeles study found that one-third of board-and-care residents reported being robbed or assaulted within a year.
While the plight of mentally ill individuals in nursing homes and board-and-care homes remained largely out of the media spotlight, homelessness, particularly mentally ill homelessness, became a dominant narrative in the 1980s. Figures like Mitch Snyder and the National Coalition for the Homeless gained prominence, challenging President Reagan and attributing homelessness primarily to a lack of housing and jobs. However, media attention increasingly revealed the significant presence of mental illness among the homeless population.
Life magazine’s 1981 article “Emptying the Madhouse: The Mentally Ill Have Become Our Cities’ Lost Souls” and the tragic case of Rebecca Smith, a college valedictorian who froze to death on the streets of New York in 1982, brought a human face to the crisis. Lionel Aldridge, a former NFL player who became homeless due to schizophrenia, further highlighted the issue in 1983. A 1984 Boston study reported that 38% of homeless individuals were seriously mentally ill, confirming growing suspicions about the link between deinstitutionalization and homelessness.
By the mid-1980s, a consensus emerged: homelessness was increasing, and the failures of the mental health system were a significant contributing factor. A 1985 Los Angeles report estimated 30-50% of homeless individuals were seriously mentally ill and concluded that the streets had become “The Asylums’ of the 80s,” a damning indictment of deinstitutionalization.
The case of Joyce Brown in 1986 further polarized the debate. Brown, a former secretary, became homeless and exhibited severe psychotic symptoms on the streets of New York. Mayor Ed Koch’s decision to involuntarily hospitalize her, despite legal challenges from civil liberties groups, reflected a growing public frustration and a re-evaluation of individual liberties versus societal responsibility to care for the severely mentally ill. By the late 1980s, studies directly linked deinstitutionalization to homelessness, with significant percentages of discharged patients ending up on the streets.
Concurrently, the 1980s witnessed a surge in the incarceration of mentally ill individuals. A 1989 review indicated a gradual increase in major psychiatric disorders among jail and prison inmates over the preceding two decades, with prevalence rates ranging from 6% to 11% across different states. By 1990, a national survey estimated that approximately 10% of inmates, around 100,000 individuals, suffered from schizophrenia or bipolar disorder, double the rate from a decade prior.
Studies showed alarming trends: high rates of arrest among recently discharged patients and the discharge of violent, seriously mentally ill individuals without aftercare plans. The phenomenon of “frequent flyers” in jails, like George Wooton in Denver, became increasingly common. Jail personnel struggled to manage inmates with bizarre and self-destructive behaviors. Adding to the complexity, civil liberties lawyers often defended the rights of mentally ill prisoners to refuse medication, even in cases of severe psychosis.
The escalating number of mentally ill individuals entering the criminal justice system placed immense strain on local police and sheriffs’ departments. In New York City, calls related to “emotionally disturbed persons” more than doubled between 1980 and 1988. These incidents often required extensive police resources, leading to the development of specialized Crisis Intervention Teams (CIT), first pioneered in Memphis, Tennessee, in 1988, to better manage psychiatric emergencies.
The 1980s also saw a rise in violent episodes committed by untreated mentally ill individuals. The decade began with high-profile shootings by perpetrators with untreated schizophrenia: the murder of Allard Lowenstein, the assassination of John Lennon, and the attempted assassination of President Reagan. As the decade progressed, such tragedies became more frequent and widely publicized.
Cases like Sylvia Seegrist, Bryan Stanley, Lois Lang, Juan Gonzalez, Laurie Dann, and Joseph Wesbecker, among many others, illustrated the devastating consequences of inadequate mental health care. These incidents fueled public fear and intensified the debate about deinstitutionalization and the need for more effective interventions. A study comparing hospital admissions in New York State between 1975 and 1982 revealed a near doubling in the percentage of patients with a history of violence in the community and a more than quadrupling in those with criminal justice system encounters.
While a comprehensive national database tracking homicides by mentally ill individuals was lacking, a 1988 study in Contra Costa County, California, found that 10% of homicides were committed by individuals with schizophrenia, all of whom had a history of hospitalization. This figure, corroborated by another study in Albany County, New York, suggested a significant link between deinstitutionalization and violence perpetrated by untreated mentally ill individuals, a problem that appeared to be on the rise.
In conclusion, while it’s a simplification to say President Reagan solely “cut” mental health care, his administration’s policies, including the dismantling of the Mental Health Systems Act and the conversion of CMHC funding into block grants, undeniably curtailed federal support for community mental health centers. These actions, coupled with the broader trend of deinstitutionalization that was significantly advanced during his governorship in California, contributed to a mental health care system in crisis. The consequences – increased homelessness, incarceration, and violence among the mentally ill – became tragically evident throughout the 1980s, leaving a shameful legacy that continues to impact mental health care in America today. The narrative isn’t just about budget cuts; it’s about a fundamental shift in approach that prioritized state control and minimized federal responsibility, with devastating results for the most vulnerable members of society.
