Leaving State Hospitals Sent Many Into Psychotic Abyss
The class of 1991 was small, 2,509 men and women to be exact, nowhere near the size of the classes of decades past.
There was no yearbook, no graduation ceremony. None of the alumni became famous. Their names mean nothing to anyone other than family members and friends, and maybe a caseworker or two.
They were the last large group of the noncriminal mentally ill housed in California’s few remaining state hospitals on July 1, 1991, when the state gave up financial responsibility for them. Soon they began leaving the institutions that had cared for them, often for years, and went on to uncertain fates.
The class of 1991 represents a fraction of the 630,000 severely mentally ill in California. But what became of these hardest of the hard cases as they were released in ensuing years reflects what happens to many such people. All too often, they fall back into a psychotic abyss--hearing voices, wandering the streets, landing again in locked wards and jails.
At The Times’ request, the California Department of Mental Health and seven counties dug through their records to determine the fate of the class of 1991. Although at least half the patients released in the early and mid-1990s appear to be living relatively successfully, more than 40% have not fared well:
* No fewer than 158 have died, some violently, many prematurely.
* At least 214 could not succeed on the outside and are back in state hospitals.
* Scores statewide are unaccounted for. In Los Angeles County alone, 284 have not had contact with a county mental health worker since 1996. Although some have seen private therapists, the county cannot say for sure where most are living. Even in smaller counties, caseworkers lose track of former patients.
“The ones who are missing may well be the sickest,” said Dr. Joyce Sutton, a psychiatrist at Napa State Hospital. “How many potential disasters do these people represent?”
* An estimated 384 simply were moved to cheaper alternatives--privately run, locked nursing homes for the mentally ill. Although some of the facilities offer quality treatment, patient neglect and abuse are reported frequently.
* Los Angeles County reports that it had 948 patients in the hospitals in 1991, 15 of whom have never left. Of those released, at least 27% have been jailed one or more times since, and 20% have been homeless at least once.
“There is a long way to go,” said California Mental Health Director Stephen Mayberg, who was appointed in 1993 when the shift was underway. “I don’t care how many pockets of excellent treatment there are. We can see how people slip between the cracks.”
State Cedes Control of Funds to Counties
The decision to move the last 2,509 noncriminal mentally ill people from state hospitals had its beginnings July 1, 1991. Starting that day, the state ceded to counties almost total control of about $1 billion a year to care for the severely mentally ill.
Using that freedom, counties moved all but 267 of their patients from state hospitals back to their home areas in the early and mid-1990s. (Of those left behind, 171 have since died.) Despite the patients’ frailty, then-Gov. Pete Wilson and the Legislature did not require that the state or counties track how the mentally ill fared once they were released.
“These people were the most vulnerable and most challenging. They would have had the hardest time surviving,” said Dr. Robert Liberman, who directed the UCLA research center at Camarillo State Hospital and worked there until it was shut in 1997. “Frankly, if you were in the [Wilson] administration, would you want to do that study . . . ? The findings would be embarrassing.”
The Times’ review shows that by 1997, the latest year for which statistics were available, 158 released patients from the class of ’91 had died. That’s 7% of those who were discharged and could be tracked. Two died within a week of their discharge; 11 others died within a month. More than a third of the deceased--57--died within a year of being released.
State officials declined to provide detailed information about the deaths, contending that patients’ privacy follows them to the grave.
Some mental health experts are not surprised by the deaths. Many of the patients were elderly and in poor health. However, based on information provided, “the death rates are higher than in the general population. No question about it,” said David Strauss, a professor of statistics at UC Riverside, who reviewed the data at The Times’ request. Strauss has done similar studies on developmentally disabled people who were released from state institutions.
“It cries out for a more thorough investigation using more detailed information,” he said.
Thirty years ago, California led the nation by beginning to empty its state hospitals in a reform push. The hospitalized population was slashed from more than 30,000 in the 1960s to 4,500 in 1991, a total that included mentally ill people who had committed crimes. Compared to the upheaval in the 1970s, what happened in the 1990s was a mild aftershock.
But although today’s numbers are smaller, there is an essential parallel: California still routinely fails to care for its most vulnerable citizens three decades after the Legislature rewrote commitment laws, gave patients more rights and opened the back wards where critics said abuses occurred.
In 1992 and 1993, as counties pulled patients out of state hospitals, services were so haphazard that one Napa State Hospital patient was discharged not to his family or a nursing home, but to a motel.
Another man, Michael, was discharged to the streets of Fairfield, a military town between San Francisco and Sacramento. A state hospital psychiatrist called Michael’s parents, warning that he posed a danger. Four days after his release, the 34-year-old man, who stood 6-foot-7, tried to barge into his parents’ home. Before police could arrive, his father was forced to shoot him, killing his son in self-defense.
“People in the system try, but it’s dollars and cents,” the father said, haunted by the horror of that day. “A lot of people like Michael slip through the cracks.”
At the time, services for the mentally ill were scarcer than they are today. But even now, when counties have improved their systems of care, failures are frequent.
The Solano County Mental Health Department moved Richard Carrico from Napa State Hospital to a board and care home in 1992. He used street drugs, speed mostly, and degenerated, only to be helped by caseworkers--until a year ago, when he was arrested after a fight.
A judge declared him to be incompetent to stand trial and sent him to Atascadero State Hospital, the most secure of the four remaining state mental institutions.
Atascadero psychiatrists, using stabilizing antipsychotic medication, returned Carrico to Solano County to face trial in June, but not without a warning. Carrico “probably does need placement in a psychiatric facility in order to maintain competence to stand trial,” a state psychiatrist wrote to the court.
A judge freed him, but no one in the criminal justice system told county mental health officials that Carrico had been released. With no place to go, he began sleeping at a homeless encampment under a freeway overpass. Mental health caseworkers caught up with him and were waiting to meet him at a homeless shelter Aug. 4, when his bludgeoned body was found. He was 40.
“They should not have put him on the street,” said his mother, Marlene Reynolds. “They should have had a board and care home set up for him, or something.”
High Homicide Rate Among Those Released
At least six members of the class of 1991 have been homicide victims. While small, that number far exceeds the homicide rate in the overall state population, where fewer than seven of every 100,000 people die annually at the hand of another.
Most of the 158 patients who died after their release succumbed much less violently. But in some instances, the patients’ release may have hastened their deaths. At least, that’s the view of Doug Black.
Black’s brother, Craig, had been an honors student at Lakewood High School. He knew Latin, played the violin and was a UCLA graduate. Schizophrenia consumed him in his 20s. He spent most of the last half of his life at Camarillo, a mission-style sanitarium that dated to the turn of the century.
In February 1997, as the state prepared to close Camarillo, Los Angeles County placed Black in the care of a private firm retained to help ease patients back into the community. His new caretakers changed his medication to drugs that state psychiatrists had tried and discarded.
Doug Black says his brother seemed to age over overnight. His skin became wrinkled, and his gait turned to a shuffle. On Memorial Day in 1997, four months after his discharge, Craig Black suffered a fatal heart attack. He was 54.
In his brother’s view, the state shirked its responsibility. “It’s hard to be around people with schizophrenia,” said Doug Black. “A lot of people cringe and walk away. I think that’s what the state did.”
Today’s state hospital population of 4,016 is only slightly less than it was at the start of the decade. But the makeup has changed. In 1991, court-approved conservators had placed 2,509 patients in the institutions. They were there “voluntarily” and could leave whenever their conservators found better places. The other 2,000 state hospital patients in 1991 had committed crimes and judges had ordered them confined.
Now, about 80% of the patients in state hospitals have committed crimes that range from minor infractions to homicide.
Only 896 are in the hospitals on so-called civil commitments; for most of these people, the stays are short, though some have conditions that are so unusual or extreme that they cannot survive outside the hospitals and will probably remain inside for the rest of their lives.
As the hospital population has changed, their campuses have turned prison-like. There is 1.6 miles of razor wire atop 16-foot fences ringing Napa State Hospital. Guard booths overlook the perimeter. Patton State Hospital in San Bernardino is reserved almost exclusively for people who have committed crimes. A majority of the patients at Metropolitan State Hospital in Norwalk have not committed crimes, but it too has razor wire and tighter security.
Behind the fences at Napa, there is an impressive array of job training, education and therapy, programs reserved primarily for criminal offenders.
“Everything was remodeled,” said Sutton, the Napa psychiatrist. “Everything is nicer. The forensic patients are doing well. If they were not forensic clients, the counties would have pulled them out long ago. Courts won’t let them out until their mental illness is in remission.”
The 1991 transformation began when Gov. Wilson, faced with an economy in tatters and a $14-billion budget deficit, gave counties broad authority over roughly $1 billion a year in state funds for mental health care. Counties embraced the idea, which gave them more money and more authority to decide how to handle the most difficult cases.
County officials could choose to pay the state more than $100,000 a year to care for a patient at a state hospital. Or they could place that same person in a private locked facility for $28,000 to $54,000 a year. For higher-functioning patients, there were board and care homes, where beds cost the county about $3,600 a year.
The choice was clear.
Most county mental health directors used the money to set up counseling programs, shelters and housing. In Solano County, Mental Health Director Gail Bataille established a program that provides intensive counseling for 40 chronically mentally ill people who otherwise would be in locked wards. It’s not cheap--$27,000 a year per person. But it helps ensure that the people, including former state hospital patients, can live on their own.
“I don’t have any question but that [the change] has been a good thing,” Bataille said. “I had a growing population. I had very, very poor community services, almost nothing. And I had 46 beds at Napa State Hospital that I had no control over. It freed up money.”
Transition Succeeds for Many Patients
Many former hospital patients have made the transition successfully, especially when caseworkers have provided intense supervision and patients have followed a strict routine of antipsychotic medication and counseling. They are people like Donald Kaufman, 52, a 1969 UC Berkeley graduate who was working at his first job when he had his initial mental episode. He went to Napa in 1975 and spent the better part of the next 18 years there.
At the hospital, Kaufman was taken care of. Sometimes, he longs for that. But he’s not alone on the outside. He lives in a group home a short distance from his parents. Marin County provides a conservator to help handle his affairs. A caseworker visits his home daily. On the back porch of his parents’ home, Donald talked of simple joys such as listening to his own music, cooking his own meals and going about his chores and errands.
“Treasure your freedom,” he said.
For many people, success depends on family involvement, which can prove difficult for aging parents.
Josephine Melara is 74, stands 4-foot-5 and takes in sewing to make ends meet. There are American flags on the front window and living room wall of the small home in Sacramento she has shared with her son, Raymond, since Sacramento County moved him from Napa State Hospital in 1995.
“It’s not easy,” she said. “I’m able to handle it by praying.”
She is a retired nurse, which helps. At any hour, she also can call Turning Point, a nonprofit agency retained by Sacramento County to help with the tough cases.
Raymond Melara, 46, keeps his bedroom tidy, goes to Turning Point for therapy and regularly takes his medication. That helps him control his anger. But sometimes he stands in the frontyard punching at the wind. Sometimes, he says, he shouts insults at neighbors.
“They know I got mental problems. They’re considerate. I respect them for that,” he said.
Raymond considers home a far better place than an institution. “Too many people, too much medication,” he said of Napa. “I do my duties, take my medication. I’m glad I’m out. I obey the law. I worked to get my freedom.”
A Large-Scale Social Experiment
Although state Mental Health Director Mayberg and some county mental health directors tried to piece together what became of the former patients, details are lacking. Officials cannot say for sure where hundreds are. The state and counties also would not disclose information that might violate patients’ privacy. Still, the information provides a glimpse at the outcome of what was in essence a large-scale social experiment.
Almost 11% of the released patients who survived and could be tracked--214 people--were returned to the hospitals, unable to make it on their own. Of those, at least 45 committed crimes and were sent back by court orders, according to the state Department of Mental Health.
Although the number of former patients jailed statewide could not be ascertained, Los Angeles County’s tracking system found that 27% of its released group had run afoul of the law.
They are people like 50-year-old Walter Davis.
Davis was at Camarillo in 1991 because his father, a physician from Seal Beach, thought it best for him. Dr. William Davis watched out for his son. He would take Walter to symphonies and other events. But biology and government finances worked against the doctor.
In 1996, he died. A year later, Camarillo closed and Los Angeles County placed Walter in a board and care home. By last spring, he had become one of his father’s worst nightmares, joining the transient asylum in Hollywood.
On May 23, Davis stood on Hollywood Boulevard and challenged a passerby to a fight, court files show. He was arrested and quickly released. By June 28, Davis had been arrested three more times. In the Hollywood jail, he rambled incoherently and talked to himself. Finally, a judge ordered him held at Metropolitan State Hospital, where he remains today.
“The system hasn’t worked for Mr. Davis,” said Los Angeles County Deputy Public Defender Norm Kava, who represents him in conservatorship matters. “Ultimately, it becomes the public’s problem.”
Others are held in a different kind of institution. At least 384 of the class of ’91, 17% of those who were released and could be tracked, are living in privately run, locked facilities. Most of these operations fare well in state inspections. Still, few offer the types of treatment that were available when the state hospitals were at their best.
The hospitals had their troubles--in 1991, Napa was sanctioned over its use of restraints and had lost its accreditation--but Napa and Camarillo both had noted researchers and were trying the newest antipsychotic medications and therapy.
“At least at Camarillo, they were trying things,” said Randy Wilkinson, whose brother, Larry, has been housed at two private facilities since his discharge in 1994.
Los Angeles County moved Larry from Camarillo to a locked nursing home in Rosemead called Green Acres. Randy Wilkinson, the one relative who visits, choked up when he recalled seeing Larry for the first time there. “I was so shocked,” Randy said. “His condition was so much worse. His teeth were missing. He was dressed in rags. His stomach seemed distended.”
Larry, 46, is a year younger than Randy. But his leathery face makes him look 15 years older. Larry is living now at Cherrylee Lodge Sanitarium, a locked 46-bed facility in El Monte with low ceilings, beige walls and fenced grounds about the dimensions of a mid-size backyard.
Randy thinks about finding a new place for Larry. But he fears making the wrong move. “There’s not a day that goes by that I don’t think about the situation,” he said.
For others, the state hospitals were akin to prisons.
As the moving dates neared, a patients’ rights organization, Protection & Advocacy Inc., promoted a self-help group at Napa. Shirley Mattos became a patient leader. Lucid, feisty and smart, she desperately wanted to return to her hometown of Modesto.
She was hospitalized because when she became angry or frustrated, or for reasons no one understood, she swallowed things--pencils and pens, mostly, but also eyeglasses, toothbrushes and paper clips. At Napa she had surgery more than 50 times to remove objects. To keep her alive, state hospital doctors inserted a shunt in her gut, so they could remove the items without scarring her further. She pulled it out whenever she could.
Napa staffers were assigned to watch her full time. It was tough duty. She was “brutally abusive to staff,” an aide wrote. Administrators moved her from ward to ward to keep aides from getting burned out.
Napa psychiatrists resisted her demands that she be allowed to return to Modesto. They wanted her to go four months without repeating her self-destructive swallowing. She never did.
‘She Was Able to Live Out Her Dream’
On Oct. 27, 1993, over psychiatrists’ objections, the county granted her wish and removed her from the hospital. It reserved a room in a well-maintained board and care home in Modesto, lined up a surgeon who would extract any objects she swallowed and assigned round-the-clock caseworkers.
“In many ways, she never belonged in state hospitals,” said Stanislaus County Mental Health Director Larry Poaster. “She was like a prisoner. She wanted out. The day came that this was either going to go on forever, or we were going to try something different.”
In the small world of patients’ rights advocates, Mattos’ release became a cause celebre. She spoke at gatherings about her experiences and testified before a legislative hearing. In November 1994, as one speaking engagement drew near, she got increasingly nervous and swallowed a pencil. When surgeons tried to remove it, Mattos hemorrhaged. On Nov. 9, 1994, a year and two weeks after she left Napa, she died. She was 39.
“There was a time when she was doing really well,” her sister, Diane Silva, recalled. “It was almost like she couldn’t cope with that.”
Some might contend that at Napa, Mattos at least was kept alive. But former Protection & Advocacy attorney Dan Pone--who befriended Mattos, fought for her release and attended her funeral--believed the system worked because Mattos controlled her fate.
“She would have died in the hospital, alone,” Pone said. “She died, but she was back home, near her family, with other clients. That year was probably one of the best, if not the best year of life. She was able to live out her dream.”
Times data analyst Sandra Poindexter contributed to this story.
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Mentally ill patients in California state hospitals:
Source: California Department of Mental Health
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Where Is the Class of ’91?
In July 1991, California changed the way it funds mental health care, prompting counties to move most patients out of state hospitals. At the time, the following seven counties had kept 253 individuals in state hospitals on so-called voluntary civil commitments. Of that group, 236 were released. Here’s a summary of what county mental health departments found when they checked on those patients’ fates:
L.A. County Patients’ Paths
Los Angeles County’s reporting does not lend itself to a similar analysis. The county reports it had 948 patients in state hospitals in July 1991. Fifteen have never been released; 26 are known to have died.
* Patients who have seen a county mental health provider in 1999
* Patients living or deceased who have been jailed at least once since release
* Patients living or deceased known to have been homeless at least once since their original discharge
* Patients discharged and returned to state hospitals
* Patients currently in Institutes for Mental Disease
* Percentages are based on 948 patients
Source: Los Angeles County Department of Mental Health
Researched by Sandra Poindexter / Los Angeles Times
The Broken Contract
This series examines failings of the system of care for California’s more than 600,000 severely mentally ill residents.
Sunday: The mentally ill often hit bottom--or land in jail--before receiving consistent treatment.
Today: A look at what happened to the last wave of patients forced out of state hospitals.
Tuesday: The controversy over laws making it difficult to commit ill people into locked treatment centers.
Stories in this series are available on the Internet at www.latimes.com