The Department of State Hospitals (DSH) was created in 2012 to assume many of the functions previously performed by the Department of Mental Health (DMH), which is being phased out. In the words of the state Legislative Analyst’s Office, DMH “struggled with the fiscal and programmatic operations of its state hospitals.” The new department’s primary responsibility is overseeing those seven violence-plagued forensic state health facilities, including five hospitals, while ushering in a new facility in Stockton.

California’s Department of Mental Health Transitioning into the New Department of State Hospitals (Press release) (pdf)

California’s history of mental health services began in 1853, when the Stockton State Hospital opened, in part to house the incurably mentally ill. In 1875 Napa State Hospital began operations as the state’s first dedicated mental health institution, taking over Stockton’s duties.

Under Article 16 of the state’s Constitution, in 1943 the California Department of Institutions was divided into the Department of Mental Hygiene—the predecessor of the Department of Mental Health—and the Department of Corrections’ Youth Authority.

By 1957, more than 35,000 patients were being treated in 14 hospitals throughout the state. In the same year the legislators passed the Short-Doyle Act, which provided matching funds to communities in order to fund local mental health services. The act was driven in part by the psychiatric community’s belief that most mental illnesses could be treated with drugs such as Thorazine, and that treatment in the communities was not only more easily accomplished because of drugs, but more effective. The Short-Doyle acts were extended to pay for 75% of costs in 1963, and a wider range of programs were funded.

The Legislature again acted in 1968, passing the Lanterman-Petris-Short Act. The new law required judicial review before institutional commitment of the mentally ill, which greatly reduced the number of individuals committed. By 1984, the state’s institutionalized population had dropped by 84%, resulting in the closing of nine hospitals. A 1990 law, the Bronzan-McCorquodale Act, gave counties primary control over mental health, and provided several revenue streams to provide funding. However, a 2000 report by the Little Hoover Commission concluded that although revenue had kept pace with the growth of population and inflation, ever-broadening social programs created a revenue crisis.

The 2006 passage of Proposition 63, known as the Mental Health Services Act (MHSA), greatly expanded the state’s definition of mentally ill to encompass a large number of the criminal population, resulting in dramatic increase in the number of cases: some 90% of the system’s patients now come from the courts. At the same time, a string of assaults and deaths in the institutions has brought a public outcry and protests from health care workers, as well as plans from the governor’s office to drastically change the delivery method of mental health services by the state. In an economic climate where the battle over the state budget consumes the majority of the legislative calendar year, proposals to change the department appear with all the regularity of contestants on a Hollywood game show.

In June 2011, Governor Brown signed a bill into law that transfers Medi-Cal-related mental health functions from DMH to the Department of Health Care Services by July 2012. And in 2012, the Legislature approved the governor’s broad government reorganization plan that created the Department of State Hospitals and gave it responsibility for DMH’s five mental hospitals and two psychiatric programs. 

Funding Public Mental Health in California (pdf)

Medi-Cal Transfer, Stakeholder Summer 2011 and Realignment Information (DMH website)

The Department of State Hospitals operates five state facilities with a combine patient population of 5,000. Each state hospital provides inpatient treatment services for Californians with serious mental illnesses, but the hospitals differ in many ways.

Atascadero State Hospital (San Luis Obispo County), which opened in 1954, is located on California's Central Coast, midway between San Francisco and Los Angeles, and is an all-male maximum security forensic facility which employs more than 2,000 staff members. A forensic facility makes determinations regarding a patient’s fitness to stand trial, need for commitment or responsibility for criminal behavior. The majority of Atascadero patients are deemed to be a threat to themselves and others, and are sent to the hospital for evaluation by Superior Courts, counties of California or the Department of Corrections (i.e., state prisons, county jails and other state hospitals.) Atascadero does not accept voluntary admissions. It has a capacity of 1,275 beds; 204 for acute/psychiatric care and 1,071 for intermediate care. In recent years, Atascadero has experienced a surge in violence, with patients attacking workers on several occasions.

Coalinga State Hospital (Fresno County), is the department’s newest hospital—a $400 million facility  opened in 2004 to relieve some of the burden from Atascadero State Hospital.  Like Atascadero, Coalinga is a maximum security facility, surrounded by a double layer of barbed wire topped fencing.  A number of sexually violent predators were transferred from Atascadero to Coalinga in early September 2005.

The hospital was the first to be built by the state in nearly 50 years, and designed to house violent sexual offenders who, at the end of their prison sentences, are deemed by the courts as too dangerous to return to society. Once remanded to Coalinga, the individuals (they are not called patients) undergo a long-term treatment program which allows them to manage their mental problems. When it reaches full capacity, Coalinga will grow from its current 900 patients to 1,500 and employ approximately 1,600 staff members.

Metropolitan State Hospital (Los Angeles County), which dates from 1915, is located is Los Angeles County’s city of Norwalk.  Unlike Atascadero and Coalinga, Metropolitan does not treat individuals charged with or convicted of a sex crime, or those convicted of murder. Its 162 acres house a patient population of just under 700, with an administrative, clinical and ancillary staff of 1,500. The hospital also provides continuing educational programs for its staff, and numerous college and university affiliations, such as psychiatric residents and medical students from the School of Medicine at the University of California, Irvine. Training for nurses and psychiatric technicians and educational internships is provided through affiliations with numerous colleges: Chapman, Cypress, Golden West, Long Beach City, Mount San Antonio, Rio Hondo Community and California State University, Los Angeles.

Napa State Hospital (Napa County), the state’s first dedicated mental institution, opened in 1875. With 500 acres, the hospital was designed as a self-sustaining facility, with dairy and poultry ranches, as well as vegetables and fruit gardens. The hospital grounds at one point encompassed 2,000 acres, and sustained more than 5,000 individuals at its peak in 1960.  

Napa is classified as a low- to moderate-security facility, and has a capacity of 1,362 patients. The hospital’s safety has recently been the center of attention, as several workers have been attacked by patients. One was murdered in 2010.

Patton State Hospital (San Bernardino County) opened in 1893. Initially called Southern California State Asylum for the Insane and Inebriates, it was renamed in 1927 for Henry Patton, a member of its first Board of managers. Patton is a forensic hospital for individuals who have been civilly committed by the judicial system for treatment. The hospital has a capacity of 1287, although the population normally numbers approximately 1,000. Patton is a low- to moderate-security facility. Like its sister hospitals in Napa and Atascadero, Patton has seen an increase in violent incidents in recent years.

In addition to its hospitals, the department operates treatment centers jointly with the Department of Corrections at Salinas Valley and Vacaville, to meet the growing demand for mental health care in the state’s prisons.  The Vacaville Psychiatric Program was established in 1988 and operates a 218-bed acute inpatient hospital and a 114-bed intermediate treatment program. An expansion of the program at Vacaville will add 64 more patients at the end of 2011.  The Salinas Valley Psychiatric Program is a 64-bed facility located in Salinas Valley State Prison and modeled on the standards of treatment at Atascadero.

A third psychiatric program is being developed in Stockton. The 1,722-bed facility is a joint project of the Department of State Hospitals, the Department of Corrections and Rehabilitation and the California Receiver’s Office.   

The Department of Mental Health is being eliminated, and many of its responsibilities are being transferred to the Department of State Hospitals. The transition began at the start of 2012, with a realignment of state level community health programs.  

The 2012-13 budget for the Department of State Hospitals proposes $1.5 billion to fund 9,953 positions in support of 6,439 patients at five state hospitals and in two psychiatric programs.  

The original budget plan for the department included funding and adjustments for the following programs, according the Legislative Analyst’s Office:

Court–Ordered Patient Admissions

In anticipation of a population increases related to court-ordered changes to reduce facility waiting lists, the budget plan shows an increase of $28.1 million from the General Fund and 277.5 positions.

Department of Juvenile Justice (DJJ) Closure

The budget plan assumes a $3.4 million budget reduction and loss of 47.9 positions because of the elimination of mental health services for DJJ inmates.

California Healthcare Facility (CHCF), Stockton

A prison being built in Stockton is expected to open in July 2013 and will provide mental and physical health care via approximately 475 beds in the Stockton Psychiatric Program. The budget reflects an increase of $11.4 million from the General Fund for mental health–related staff positions.

Alarm Systems at Napa, Metropolitan, and Patton State Hospitals

The new Personal Duress Alarm System is being deployed at the Metropolitan and Patton State Hospitals at cost of $27.2 million. This also includes $446,000 for maintenance of these alarm systems at the Napa State Hospital.

Fire Sprinklers and Fire Alarm System Replacement at Napa and Metropolitan

A funding increase of $14.1 million will pay for fire sprinklers at Napa and Metropolitan State Hospitals skilled nursing facilities. The budget also assumes $15.5 million will be allocated to replace the fire alarm system at the Napa State Hospital.

Treatment in County Jail of Those Incompetent to Stand Trial

The governor’s budget includes a funding decrease of $3 million resulting from a shift of treatment of defendants found to be incompetent to stand trial (IST) to county jails, rather than state hospitals, when medically appropriate.

Department of State Hospitals (California Mental Health Directors Association) (pdf)

2012-13 Budget Analysis: Oversight and Accountability at State Hospitals (Legislative Analyst’s Office)

Contractors Overpaid           

California overpaid independent contractors $49 million between fiscal years 2005-06 and 2009-10, and much of the work was unnecessarily caused by a lack of coordination between the Department of Mental Health and the Department of Corrections and Rehabilitation, according to a report by State Auditor Elaine Howle.

But the problems that led to the overpayment point to colossal mistakes by both departments that go beyond financial errors.

The state Sex Offender Commitment Program enacted in 1996 was aimed at identifying the small population of incarcerated sex offenders predisposed to violent behavior because of mental disorders and having them referred to DMH for evaluation.

Passage of Jessica’s Law (Prop. 83) in 2006 expanded the pool of potential offenders five-fold and the Corrections department, misconstruing state law, referred every one of them to DMH. Over a four-year period, less than 1% of the 30,000 referrals were deemed by DMH to need commitment. Thousands of those sent over by Corrections were repeat offenders whom the DMH had already evaluated as not posing a high risk to public safety.

But DMH was overwhelmed by the workload and was forced to hire contractors. About 60 contractors were needed each year and they billed the department at $124 per hour, twice the rate of $72 per hour—including benefits—for psychologists on the DMH payroll.

Scott Kernan, the Corrections department’s undersecretary for operations, acknowledged the problems in a letter to Howle.  “We agree that improvements can be made in streamlining the process,” Kernan wrote, “and have already implemented steps to improve the timeliness of our referrals to DMH.”

Sex Offender Commitment Program (State Auditor) (pdf)

Millions Spent On Contractors for “Unnecessary” Mental Health Screenings (by Dave Paresh, Sacramento Bee)

Expensive Socializing

It only merited one paragraph in the state Auditor’s report on seven “Improper Activities of State Agencies and Employees,” but it was singled out in the report’s summary as a prime example of the “waste of state funds, misuse of state resources, falsification of records, inexcusable neglect of duty and failure to monitor time reporting” found during the one year investigation. 

Arthur Kassel, a longtime senior official at DMH and an appointee of former Governor Pete Wilson, was accused of wasting $51,244 socializing with celebrities and attending gala events under the guise of working on an “anti-stigma” program.

Kassel is said to have attended the Golden Globe Awards, the World Magic Awards, a Julio Iglesias concert and other events, allegedly attempting to recruit celebrities as pitchmen for the program. “People who have mental illnesses have no voice," Kassel said. "We were hoping if the budget ever got fixed in California that we would be able to do a star-studded show to tell people what the problems are.” None of the celebrities Kassel talked to ever recorded a radio ad or participated in a public event on behalf of the department about the problems faced by the mentally ill.

Kassel denied the money and time were wasted, saying that money was never budgeted to allow the anti-stigma program to move forward. State Auditor Elaine Howle disagreed that the money was properly spent. Howle said that that neither Kassel nor his immediate supervisor were able to cite “any measurable benefit that the state garnered as a result of the senior official’s interaction with celebrities at social and entertainment events in the name of Mental Health’s anti-stigma program.”

Kassel, of Beverly Hills, was not identified by name in the audit. The report refers to him only as a “senior official.” But Kassel confirmed in published newspaper stories that he was, in fact, interviewed by auditor investigators about his work for the “anti-stigma” program and his attendance at attendance at celebrity events.

Ex-California Official Defends Socializing with Celebs on Public Dime (by Patrick McGreevy, Los Angeles Times)

Investigations of Improper Activities by State Agencies and Employees (State Auditor) (pdf)

Hospital Chief Convicted of Child Molestation

Claude Edward Foulk, former director of Napa State Hospital, was sentenced in February 2011 to 248 years in prison for sexually assaulting his adopted son for a decade. Four other men testified that they had been abused by Foulk while in the foster care system and seven other men came forward to accuse Foulk.

Foulk’s son, now an adult, was also a foster child. Charges could only be filed in the son’s case because of the statute of limitations. 

Head of Napa State Hospital Accused of Child Molestation (by Martin Espinoza, Santa Rosa Press Democrat

Former Mental Hospital Director Convicted of Molesting His Son (by Shan Li, Los Angeles Times)

Former Hospital Director Sentenced to 248 Years for Sexual Assault (by Ryan ZumMallen, Long Beach News)

Claude Edward Foulk Gets 248 Years (by Christine Pelisek, The Daily Beast)

High-Paid State Employees

More than 300 psychiatrists and other medical professionals working for the Department of Mental Health were among 1,400 state employees paid in excess of $200,000 in 2010.

The information was gleaned from a database compiled by State Controller John Chiang and made public in July 2011. The database lists state positions by title and is sortable by department, salary range and total wages, but does not include names of people. 

The database lists seven DMH employees as making more than $400,000 in “Total Wages Subject to Medicare (Box 5 of W-2).”  Forty were listed at between $300,000 and $400,000.

The top DMH earner was a “Salinas Valley Psychiatric Pr” at $478, 621. His classification was listed as “Senior Psychiatrist (Supervisor), Correctional And Rehabilitative Services (Safety) (Range Q).”

California Pays More Than 1,400 Workers in Excess of $200,000 (by Jack Dolan, Los Angeles Times)

Government Compensation in California (State Controller)

Patton State Hospital

In 2006, the U.S. Justice Department found “significant and wide-ranging deficiencies in patient care provided at Patton [State Hospital].” The findings were published in a report by the department’s Civil Rights Division after an onsite inspection of the facility.

“Patton fails to provide a reasonably safe environment for its patients,” the report said, noting that violence was a common occurrence. Patton had reported 500 patient-on-patient assaults in the six months preceding the visit by investigators.

“Patton also fails to keep patients reasonably safe from self-harm,” the report said. “Of great concern is the high number of suicide attempts by hanging.”

The report criticized the facility for failure to have an effective management system, including the tracking, investigating and reporting of incidents.

“Patton's psychiatric supports and services substantially depart from generally accepted professional standards of care and expose patients to a significant risk of harm and to actual harm,” the report said. It found psychiatric assessments and diagnoses substandard. The “serious harm resulting from these deficiencies” took many forms:  inappropriate medication, excessively long hospitalizations, increased risk of relapse after release, and “an overall lower quality of life.”

It wasn’t the first time the federal department found a facility run by the Department of Mental Health sorely lacking.

“Conditions of care and treatment at Patton in psychiatry, including pharmaceutical services; psychology; medical care, including general medical services, infection control, physical and occupational therapy, dietary, and dental care; nursing services; placement in the most integrated setting; and protection from harm and quality assurance, are materially similar to those outlined in the findings letters of 2003 and 2004 regarding Metropolitan State Hospital,” the report said.

Letter to Governor Arnold Schwarzenegger (U.S. Department of Justice) (pdf)

Patton State Hospital Has National Reputation (by Harvey M. Kahn, El Chicano Weekly)

Violence in State Mental Hospitals

Hospital workers and the unions that many of them belong to are pressing state legislators for a solution to the growing problem of violence in California’s state mental hospitals. The trend of violence at the five facilities has shown an alarming growth in recent years, and was brought to widespread attention by a patient’s slaying of a psychiatric technician at Napa State in October 2010.

Democratic Assemblyman Michael Allen, a former psychiatric nurse, chaired an Assembly Select Committee on Hospital Safety in August 2011 to explore solutions to violence at California’s five psychiatric facilities.  “Last year we had over 8,000 aggressive incidents and over 5,000 injuries,” Allen said. “Every one of those incidents is a tragedy in its own right.” 

The Assembly hearing began just days after Napa State Hospital patient Jess Willard Massey was sentenced to 25 years to life in prison for murdering 54-year-old Concord resident Donna Gross, a psychiatric technician, at the hospital in October 2010. Gross was strangled in a courtyard of the hospital and was robbed of less than $2 in cash, some jewelry and gum. Napa County Sheriff’s Captain Tracey Stuart testified that the victim’s watch, two necklaces and her earrings were found in Massey’s room and the gum was found in a trash can on Massey’s ward.

Massey had been sent to Napa State Hospital as a result of his plea of not guilty by reason of insanity on charges of stabbing a woman in a Sacramento parking garage in May 1996.  He has agreed not to appeal his conviction for Gross’ murder and is expected to spend his sentence in prison, rather than at a mental health institution.

Department and Hospital Malfeasance . . . ?

At the legislative hearing, Dr. Patricia Tyler, a Napa psychiatrist, told the committee that staff members had written numerous memos to DMH officials before Gross’ death  complaining about safety issues and making suggestions about how to correct them. And the Los Angeles Times reported that “attacks on staff in the second quarter of 2010 doubled to about 200 compared with the same period of 2009, and patient assaults against one another soared about six-fold to 692. Napa State had previously been sued in a 2006 by the U.S. Department of Justice to implement safety reforms.

California’s Division of Occupational Safety and Health also faulted the hospital for faulty alarm systems, inadequate employee training to deal with the increasingly violent patient population and assault investigations that “lacked analysis of the cause and thus were ineffective in preventing future occurrences.” Cal/OSHA fined the hospital $100,000 in connection with the slaying, contending that the hospital neglected to restrict the movements of violent patients—including the man charged in the strangling.

. . . Or a Flawed System?

Department of Mental Health Acting Director Cliff Allenby defended his department in front of the Assembly committee hearing, noting that more than 90% of current patients had been arrested or convicted of crimes and sent to the hospitals by the criminal courts. He said that as recently as the mid-’90s four-fifths of the patients were committed by the civil courts. Allenby said that staffing ratios need to be re-examined and suggested that special units for the worst aggressors be created, which would help to improve the safety of the grounds.

Not all agree that increasing the level of security is the answer. “You have to be somewhere between a hospital and a prison, ” said Brad Leggs, facility president for the California Assn. of Psychiatric Technicians. “Now we have a barbed wire fence up and we have police officers guarding the perimeter. There’s a prison mentality.” And at the California Medical Facility at Vacaville, some clinicians question the use of cages to move dangerous mentally ill prisoners during therapy sessions.

In the 1950s, psychiatric professionals determined that with the use of drugs the mentally ill could be treated without being institutionalized. A decade later, they argued that the involuntary confinement of the severely mentally ill was wrong. As national sentiment and policy shifted to deinstitutionalizing the mentally ill, the state’s mental health hospital population decreased dramatically, forcing a reduction in the number of state hospitals from 14 to five. Psychiatric care moved to a less restrictive, and some argued, more open method of treatment, enabling more patient freedom.

But Proposition 63 turned the mix of the patient population upside down by making  criminal courts the primary gateway for entrance into the system, introducing a large number of violent offenders into a loosened structure. Additionally, California was mandated by the Justice Department to put into effect a 92-page plan, covering everything from psychiatry to dentistry to nutrition, which came out of a civil rights investigation into the state’s hospitals. California is the only state where Justice has imposed these rules on hospitals that exclusively treat mentally ill criminals. 

Some blame the increase in violence to the new rules which require massive amounts of documentation. “Spending more time on paperwork than you are treating the patient,” argues Ramona Goodman. “That's really the security problem right there.” Goodman was attacked and beaten by a patient in 2008 at Atascadero. She has since left the job at the hospital.

Many employees share skepticism about parts of the plan that call for patients to identify their own goals and interests in choosing treatment. That, they say, is a poor choice for a psychiatric hospital treating felons and people who have a history of committing violent crimes.

“This level of violence is unacceptable,” according to Republican state Senator Sam Blakeslee, who has met numerous times over the years with employees at Atascadero State Hospital. “I have constituents who . . . work in the facility that are just distraught about their sense of threat and risk and potential injury,” he said in an interview with National Public Radio. “And it’s just an inherently dangerous population.” Blakeslee said he has been shocked by the rising degree of danger.

SEIU Local 1000, which represents many of the workers at the state’s mental hospitals, has organized protests at hospitals and in Sacramento and issued demands that the violence be addressed. The union organized a “Safety Now” coalition after the October 2010 murder of psychiatric technician Donna Gross at Napa, to improve the security of patients and employees. It has since expanded to include other Department of Mental Health facilities, and now includes AFSCME Local 2620, the California Association of Psychiatric Technicians (CAPT), the California State Law Enforcement Association, and the Union of American Physicians and Dentists (UAPD).

There are numerous bills making their way through the legislative process which are aimed at making the hospitals safer. One bill, SB 796, sponsored by Blakeslee, passed both houses and was signed into law by Governor Jerry Brown. It makes it a misdemeanor for visitors and staff to smuggle cell phones, USB cards, wireless cards, tobacco and cash to patients in mental hospitals.

“The public has a right to expect that these individuals will get the treatment to make them less dangerous, because ultimately many of these people will be back on the streets,” Senator Blakeslee said. “They'll be our neighbors, they'll be at our grocery stores. Our kids will walk by their homes.”

Violence at State Hospitals Spurs Calls for Change (by Lee Romney, Los Angeles Times)

Violence Surges at Hospital for Mentally Ill Criminals (by Ina Jaffe, National Public Radio)

California Mental Hospitals Are Dangerous, Legislators Told (by Lee Romney, Los Angeles Times)

Patient Sentenced For Murder of Napa State Hospital Worker (CBS)

Regulators Fine Napa State Hospital $100,000 over Death of Worker (by Christina Jewitt, California Watch)

Former Departments of Mental Health and State Hospitals Directors

Cliff Allenby, 2012-2015

Stephen W. Mayberg, 1993-2010

William Mayer, 1991-1993

Dr. D. Michael O’Connor, 1983-1990