California: Good Aims, Bad Results

Many of the people living on Los Angeles’ streets lack health as well as homes. They were put there by social policy, legacies of the mid-1960s when California was a laboratory for reform--and they sit there as another reminder of reform gone awry.

In 1967 the California Legislature passed the Lanterman-Petris-Short Act (LPS) which changed the state’s mental-commitment laws to limit involuntary detention of all but the most gravely mentally ill and to provide a “patients bill of rights” regarding treatment.

With the help of conservative Republican Assemblyman Frank Lanterman of La Canada (who liked to tell the American Civil Liberties Union that he had championed the rights of mental patients long before it did), the bill was pushed primarily by a group of young, liberal activists on the Assembly Office of Research staff. It was sold to Democrats as a civil-rights measure and sold to Republican Gov. Ronald Reagan as a savings--community care, without the long-term costs of custodial care in state hospitals, would cut California’s mental health care costs.

Nearly 20 years after its enactment, the bill is now blamed, at least in part, for the problems of the homeless. Its emphasis on deinstitutionalization, some policy analysts claim, has placed too many people on the streets who should, for their own sake and society’s, be hospitalized for treatment. This is not what supporters intended but the evidence is all too visible.

The bill provided for “state-of-the-art” deinstitutionalized treatment of mental illness; it fit Reagan’s mandate to “cut, squeeze and trim” government expenditures. California would get out of the business of providing direct services to mental patients who would no longer be housed in state institutions. The liberal reformers had traded institutional care for advanced services in the community.

What the reformers didn’t know--or didn’t understand at the time--was that neither local governments nor private agencies would provide sufficient community services. That is where Lanterman-Petris-Short truly failed.

One mental health professional who helped draft and move the original legislation said, “In our zeal to move people out of very restrictive, very inhumane places, we forgot that there were a whole variety of supports that were being provided (by institutions) and we neglected to find adequate ways of replicating them . . . we had a simplistic notion that basically what you could do is take people out of the institutions, move them into the community and provide outpatient mental health care. But what we forgot is that institutions provide people shelter, food, health care and a whole variety of other basic human needs.”

As the political and economic climate continued a conservative shift, a trend the reformers hadn’t expected, state and county programs offering community services were cut back. For a while federal agencies, often by default, undertook major responsibility for maintaining housing, job training and counseling programs. Then federal cutbacks in such appropriations and the Reagan Administration’s shift to block grants for mental-health funding exacerbated the problems that LPS didn’t address--more shrinkages the reformers failed to predict.

How could they have foreseen that their protestations of cost effectiveness would work too well? Or that Reagan, the governor who gave California its liberalized commitment laws, would become President of an Administration that illuminates a failure to address the linkage of community commitment to the availability of other social programs?

Federal cutbacks in housing and social services have put people more at risk, particularly those people Lanterman-Petris-Short sought to protect. Less able to cope with the streets--let alone with society at large--they are becoming an increasingly obvious part of the state’s homeless population. Among the homeless, 30% are estimated to suffer serious mental illness.

But it is dangerous to blame California’s commitment laws alone for the problems of the homeless. There are mentally ill men and women on the streets of Los Angeles for reasons larger than denial of treatment; by itself, treatment doesn’t offer a bridge back from illness to a home, a job, food to eat.

As one observer put it, “LPS is the assertion of some very basic rights which are hard to argue with. The problem is that they were being exercised in a vacuum with none of the attendant supports and backup systems in place to make it viable.” And until recently, there wasn’t much thought given to that omission by state policy-makers.

There are lessons to be learned as the Legislature, the state administration and the mental-health constituencies approach the increasingly hot political issue of changing commitment laws. And there are some very important policy traps:

Deinstitutionalization ought not be used as an excuse for the homeless problem, nor should it be an excuse for government or private agencies not living up to their responsibilities for providing services.

And reforming Lanterman-Petris-Short ought not to be used as an excuse for the wholesale movement of the homeless into institutions. Tinkering with commitment and medical treatment standards will neither erase the social ills of our streets nor will it cut the costs of dealing with them. If LPS were repealed tomorrow, in favor of adequate institutional care, allocations for the five state mental hospitals (budgeted at $324.5 million) would skyrocket.

As reformers and critics of reform continue to go about their business of pointing with pride--or chagrin--at the accomplishments--or failures--of our government institutions, they ought to be alert to the unanticipated consequences of reform. Be careful of what you wish for, a wise person once said; you may wind up getting what you want.

Reform can never be a one-shot deal; it is a process. Nothing can be corrected for all time in a state where population and politics are in constant flux. Consequences need to be watched, evaluated and reshaped by midcourse corrections when necessary. Attention must be paid.

That takes energy and commitment--on the part of policy-makers, the public and the media.

Without constant overseeing, the unintended consequences of reform will continue to thwart the economic, political or social goals of this state and will feed the cynicism that citizens and government show toward each other.

The lesson of Lanterman-Petris-Short is that policy gridlock is one unanticipated consequence Californians cannot afford; 20 years is too long for any policy to stand uncorrected or unresolved. Such inattention lines the sidewalks.