A World That No Longer Exists? Deinstitutionalization, Danger, and California’s Senate Bill 43

During the 1950s and 1960s in the United States, old asylums closed (3). The reasons for deinstitutionalization were complex. President John F. Kennedy signed the Community Mental Health Act of 1963, which gave federal grants to states for the construction of community mental health centers, incentivizing the closure of state hospitals. The rollout of Medicaid in 1965 furthered “transinstitutionalization,” because states could access more federal matching funds if mental health care was provided in nursing homes rather than in state hospitals (4). This shift was made clinically practical by new neuroleptics such as chlorpromazine, which sedated patients who were previously intractably agitated (5). The passage of the Ervin Act of 1964 limited the scope of involuntary commitment of citizens in the District of Columbia, requiring patients to both have a mental illness and meet a “dangerousness” criterion (6). Critically, this principle served as an exemplar for states revising their own civil codes in subsequent years as they deinstitutionalized.

In California, these trends converged at a unique time. The governorship of Ronald Reagan, inaugurated in 1967, was a prelude to Reagan’s presidency in the 1980s: the era of big government ended first in California. Reagan’s desire to reduce the state budget linked him to the “New Right” politics of deinstitutionalization, because closing large, expensive state psychiatric hospitals was also a clear way to shrink the size of government. As one of his campaign pledges, Reagan planned to cut spending on state programs by about 10%, affecting the budget of California’s Department of Mental Hygiene (DMH) (7). More pointedly, he planned for the elimination of about 15% of personnel at DMH in particular, curtailing what he referred to as the “hotel operations” offered at DMH facilities (8). California psychiatrists decried these cuts, asserting that patients would commit suicide and that “hospitalized children” would need to be placed “in straightjackets” (8). Although the worst fears of California psychiatrists did not materialize for various reasons, the debate cast Governor Reagan as an opponent of mental health.

Enter Republican assemblyman Frank Lanterman. By the late 1960s, Lanterman had established himself as a defender of deinstitutionalism, given his support of the Short-Doyle Act of 1957, a bill expanding community mental health resources (9). Lanterman, in concert with Senators Nicolas Petris and Alan Short, continued this agenda by authoring the eponymous LPS Act to regulate California’s system of involuntary commitment. Among seven articles of intent, the LPS Act pursued several ends of deinstitutionalization: it aimed “to end the inappropriate, indefinite, and involuntary commitment” of those with mental illness, “to safeguard individual rights through judicial review,” and of course, “to guarantee and protect public safety” (10).

Governor Reagan, to limited fanfare, signed the LPS Act in 1967. In a contemporary piece in Science, one author hypothesized that the “budget battles” and “anger at Reagan’s cuts” to DMH earlier that year seemed to “have helped in getting the legislation through” (8). The LPS Act was also politically useful for Reagan. The governor could both shrink the state mental health infrastructure and do it under the mantle of protecting people from peril. It was a system that rested upon twin values of “starving the beast” and control of the dangerous (11).

When it went into full effect on July 1, 1972, the LPS Act introduced “dangerousness” to California. The Act constrained the types of patients who could be detained, now being only those who represented a danger to self, a danger to others, or were gravely disabled (i.e., unable to provide for their food, clothing, or shelter). LPS criteria could only be met as a result of a qualifying mental health condition, such as schizophrenia, bipolar disorder, or borderline personality disorder. The Act set time limits on involuntary holds, guaranteeing regular reassessments by courts to guarantee patients’ due process. In narrowing the criteria for involuntary hospitalization, the population of California’s state hospitals began to shrink. The overall patient population was 37,000 in 1955, and by 1983—the midpoint of Reagan’s first presidential term—the number shrank to 2,500 (12). Over the succeeding decades, little changed around the core structure of the LPS Act, aside from a few instances of case law related to implementation—for instance, establishing legal procedures for the involuntary administration of medications in the Riese decision (1987) or the particulars of conservatorship for patients with major neurocognitive disorder in the Karriker (2007) and Kennebrew (2013) decisions (13–15).

The long-time stasis of the LPS Act reasonably raises the question of whether the dangers that California legislators observed in 1968 still threaten society in 2024. The perceived incongruence between contemporary concerns and historical ones evidently motivated recent legislating. Rather than radically reimagining California’s system, however, the LPS status quo was simply rebalanced by SB 43. The bill tweaks the dangerousness standard to consider that substance use disorders can lead a patient to be a danger to self, a danger to others, or gravely disabled, while at the same time liberalizing the definition of gravely disabled. This change will have the effect of swinging the pendulum of involuntary hospitalization back in the other direction. Considering substance use in assessing a patient’s dangerousness—and broadening the definition of dangerousness—will mean more involuntary treatment in California. Given the prevalence of substance use, and its relationship to suicidality, violence and homicidality, and disabling psychosis that affects a patient’s ability to obtain food, shelter, clothing, and now medical health and personal safety, more patients will be placed on holds and ultimately conserved (16–18).

The question is whether this revised dangerousness balance point will lead to better, more ethical outcomes for patients. Over the past 50 years, the legal framework of the LPS Act has led to a particular psychiatric ethics in California. It has made psychiatrists serve as both doctor and magistrate, required to both assess patients’ clinical situations and apply the dangerousness standard to determine whether to deploy state power to detain them. There is little to suggest that this sort of doctor-patient relationship will change with SB 43. There are additional pragmatic concerns as to whether California is prepared to accommodate a likely increase in the psychiatric inpatient population. Contemporary patient rights discourse reverberates with the echoes of debates held over a half-century ago, with some reasonably concerned about incipient reinstitutionalization (19).

The passage of SB 43 was argued to be a major overhaul of California’s mental health system when it passed in October 2023. Notwithstanding the ambitions of the state’s politicians, however, it is likely that the state’s psychiatrists will continue to practice in “a world that no longer exists.” This is because SB 43 introduces a quantitative legal change rather than a qualitative one. It represents but a swing of the same pendulum of state power, governed by the same structures of involuntary hospitalization, the same ethics of dangerousness.

Perhaps a revision in our ethical commitments is necessary to meet contemporary challenges. California psychiatrists must ask whether we are comfortable with the control of dangerousness sitting at the core of our practice. We may reflect that other values, such as solidarity, care, or love, could inspire our system (20–22). In considering the history of deinstitutionalization and complex legacy of California’s civil code, the hope is that psychiatrists can better engage in the informed advocacy—in our clinical practice, in legislative circles, and in broader society—that will allow us to actively bring into being a new ethical world, rather than passively accepting paradigms of the past.