Psychiatric wards are much-maligned in popular culture. In movies or television, they're usually white, empty hallways stretched for miles. Sometimes, they're dim spartan rooms of sobbing patients. Often, electroshock therapy and straight jackets feature heavily in the depiction.

In truth, mental hospitals are fairly mundane places. Hallways look like hospital hallways, with neutral paint and linoleum floors lit under fluorescent lights. Bathrooms have doors that don't lock. Patients tend to be very caught up in their own heads. When approached, they generally talk about little except their personal attempts at recovery.

I would know. The summer before I turned 18, I was hospitalized, or "inpatient," for three days when I had what my doctor decided was a "break from reality." In that Bay Area medical center, I was placed in a partial hospitalization program, or P.H.P., after I got kicked out of high school for absenteeism caused by mental illness. That meant that every morning my mom drove me to the hospital. There I spent the day in group therapy sessions integrating art and cognitive behavioral treatments, which challenge habitual thought processes.

For the short time I was in the psych ward about a decade ago, we weren't allowed to wear our own shoes. Officially this was so patients couldn't hang themselves with their shoelaces. Whispers in the ward speculated that the real reason was because nurses didn't want us to be able to run away. Unlike movies, where they forcibly medicated patients, the nurses simply offered me a rotating assortment of pills, some little and blue, some round and yellow. But they made it clear that if I wanted to leave after 72 hours of observation, I would take the drugs they gave me, so I did.

All in all, the experience was more boring than anything. They let me out after three days. Many mentally ill people aren't as lucky: they either don't get help at all or end up in cycles of treatment that solve nothing. Right now, California is seeing mental illness become a growing challenge in schools, workplaces, encampments, on public transit and the streets.

Its government is trying to do something about it. In a press conference on Mar. 21, 2024 in L.A., California Gov. Gavin Newsom said, "We're here to modernize our thinking … To fundamentally reshape and reform the approach we take to address the issue of mental health, substance abuse disorder and challenges that continue to vex us out on the streets and sidewalks."

Newsom added, "If there's ever been a unity agenda, it's this."

In 2021, the most recent year data from the National Library of Medicine is available, there were about 7,700 psychiatric beds available in California for patients admitted four days or less, including state hospital capacity. That's a drop in the bucket given that about 335,000 Californians live with schizophrenia alone, according to Mental Health Center. In the last year, California saw legislation geared towards providing more funding and resources for mental health care, rehabilitation, behavioral health — and more beds in psych wards.

"This is, as was stated, a historic day," said Newsom, talking about the passage of Proposition 1, a program labeled "Treatment not Tents" by California's government. Prop 1 will use existing state funds for those with mental illness, substance abuse and homelessness. "That means little if we can't deliver now on the promise — I say this all the time, program passing does not mean problem solving."

Legislation such as Prop 1 promised, as Newsom said, to provide aid for the mentally ill. But it's not just financial resources that they need. Experts say that the public perception of people with serious mental disorders in society isn't improving at the same rate as the perception of less serious conditions like anxiety and depression.

Instead, when politicians talk about severely mentally ill people, it's often to illustrate a problem with drug abuse or a lack of housing for some of the most vulnerable Californians.

"People clearly recognize the urgency of the crisis at hand … anywhere in the state of California," Newsom continued in that press conference, addressing what he indicated were common accusations of unhoused mentally ill people self-medicating on the streets of California. "There's no state in U.S. history — this is objective and we can back this up — that's now doing more to address the issue of mental health and address the issue of substance abuse disorder than the state of California."

So what is California planning on doing about this?

How crazy is too crazy?

In today's age of TikTok therapy and #SelfCare culture, it's easy to say many, especially young adults and teenagers, are more sensitive to mental illness. However, Dr. Erin Lee Kelly of Thomas Jefferson University suggested mental illnesses are ranked, with society seeing some conditions as less sympathetic or acceptable.

"Research has confirmed that over time, in general, people's attitudes around mental health issues have become more accepting. There is still a difference in how we think about people with psychotic disorders,"" said Kelly, grainy and washed out over an early-morning Zoom call. Kelly, a psychiatrist who works to improve care for people with serious mental illnesses and substance use disorders, explained that psychotic disorders involve a mental loss of contact from reality, or psychosis.

Psychosis — the root of the pejorative term "psycho" — isn't what the media makes it out to be. People think psychosis involves violence, but that's not necessarily true. A psychotic break from reality, more scientifically called an episode of psychosis, means delusions, hallucinations or a combination of symptoms.

Hallucinating means anything from rarer aural hallucinations ("hearing voices") to a feeling of bugs crawling down your back. Extreme delusions could include the persistent belief that an alien being has crawled inside your skull and is controlling your life. They may be the nagging feeling that everyone you meet is lying to you.

In my experience, psychosis feels a lot like fear.

When I was in P.H.P., the first thing the doctors did was put me on antidepressants. As it turns out, selective serotonin reuptake inhibitors, which many antidepressants are, make my problems worse. On those meds, I went days without sleeping. In high school, even when I appeared happy, I was treading water fast. I chewed my fingernails down to nothing. I got angry, scared and didn't know how to calm down. Looking back, I posed far less danger to others than to myself.

While in some situations psychotic people lash out and hurt someone, illness isn't inherently violent. Multiple studies throughout the years found that psychotic people are not more dangerous than mentally well people, said Kelly. In fact, that's a refrain I've heard from doctors and psychologists again and again: severely mentally ill people are more likely to be the victims of violence than the perpetrators of it.

So where does this delusion about violence come from? According to Dr. Drea Letamendi, psychologist and consultant on mental illness in entertainment media, it's built into television and films. Overall, she said, mental illnesses are underrepresented and poorly portrayed in popular media, but there's additional inaccuracy in how entertainment portrays certain severe mental illnesses.

For example: "Dissociative identity disorder [D.I.D.] — this used to be called multiple personality disorder — is in film and TV much more than it exists in real life," said Letamendi. "That's a disservice to the [D.I.D.] community and to audiences, because that disorder is simply not as common, whereas there might be others such as depression and anxiety."

Dissociative identity disorder, commonly called having multiple personalities, is diagnosed in 1.5% of the global population, according to the National Library of Medicine. It's not common and generally doesn't result in violence, unlike most of the media portrayals of the disorder, said Letamendi. The 1979 movie Sybil and the 2016 movie Split both portray characters with D.I.D. in a fairly sensationalized way. Split in particular shows the character as being a perverse and occasionally extremely violent person, which Letamendi indicated wasn't accurate to the illness.

"Depression and anxiety, anxiety in particular, [are] the more common mental health conditions that a lot of people are struggling with right now," Letamendi said, "It seems as though some of the folks who run these industries and entertainment, understand that characters who are quote, 'crazy and unhinged' are interesting to audiences."

There's more. Attitudes towards psychotic disorders may be getting worse, said Kelly, even as the attitudes towards unipolar depression and anxiety improve over time.

"A research study suggested that people had a greater desire for distance for people with a psychotic disorder and more so relative to other mental health conditions," said Kelly. "That was a generational increase over time, that younger generations were even more concerned."

She admits: "It's been a little while" — about 24 years — "since that study was done. But I think that the premise might hold true still."

Dr. Erin Lee Kelly on the social attitudes surrounding psychotic disorders. (Photo courtesy of Erin Lee Kelly) [TRANSCRIPT]

"A psychotic disorder is something we associate with people having impulse control issues, and people worry about what that means for safety. The literature actually is very clear, in numerous studies, that people with serious mental illnesses are actually more likely to be the victims of violence than to be the perpetrators of it. We think about someone's essence as being their mind. And so maybe that's the challenge, is that we confound someone's identity too much with like, the sort of vagaries of their mental health on a daily basis, and that's kind of problematic. Why is it a condition like diabetes can be something that people accept is something that we need to provide care for, for life, because it's a condition and it's not someone's fault? Why would you take away someone's insulin once they started doing better, and how we have very different attitudes about what a mental health issue is, and what resources we need to provide someone so that they can, you know, get to their best place and stay there and not just sort of pull the rug out from underneath them every time they start to do better?"

Letamendi said that social perception of mental illness is shaped, at least in part, by entertainment and news media, but Gen Z is considered a generation that cares about mental wellbeing. Today, do people really still discriminate against the severely mentally ill?

Sure. I've seen it. A classmate in undergrad who told me she was on medication for generalized anxiety disorder, but not to worry, because she "wasn’t bipolar or anything." A coworker who told me that he thought "those schizophrenics" should be executed or "at least" locked up. A doctor refusing to treat my sinus infection because she decided the real problem was that I must have gone off my meds. Every time someone didn't believe that I'm as ill as I am because I "present well," in the words of my psychiatrist.

Social stigma isn't the only issue people with severe mental illnesses face. Abuse and mistreatment are problems, too, said Kelly.

"A lot of times when people hear about mental health issues, they think about mass shootings, they think about these big sort of media grabbing events," Kelly said. "But actually, what is more likely is that people who have a psychotic disorder are more oftentimes in neighborhoods that are unsafe and so they're subjected to a lot of the same sort of dangers that anyone who lives in a low income or more unstable neighborhood might be subject to. They're more likely to be victims of community violence, interpersonal violence and things like that."

A 2001 study published in the American Psychiatric Association's journal found that schizophrenic people are 14 times more likely to be the victims of violence than to perpetrate it. Research shows that domestic violence, police brutality and medical mistreatment are all not uncommon.

"It's known that people with serious mental illnesses tend to die about 25 years before their peers without a mental illness," Kelly said. "That's largely because of underdetected and undertreated physical health problems … I can easily see how within a medical setting someone's mental health issues might mean that the treatment team doesn't interact with them the same way that they should."

The issue here is called "diagnostic overshadowing." Kelly explained this is when doctors assume that a patient's physical health needs are caused by their mental health condition. (Think of the story I mentioned about my doctor not giving me antibiotics.) It leads to medical mistreatment, which hospitalization may compound.

In all this, nearly one in seven adults in California experiences mental illness, according to a 2023 report put out by the state. What steps can California take, given the flaws in the system, to get people the help they need?

What are we going to do about it?

San Francisco City Hall is a grand building. Violin music floated down from the rotunda while a janitor picking up debris pushed a rolling trash can through the gilded doors. Half a dozen sets of bride and groom in black tie stood just inside security, waiting for their turn to tie the knot.

Outside, the Civic Center Plaza was mostly cleared of homeless people.

A few dotted the grass, sunbathers who had everything they own laid out in bags around them. A few more sat in the shade of the San Francisco Public Library. One man stood at the base of a statue, holding his head and mouthing wordlessly at the sky. As I walked by, he looked at me before turning his face back up.

"We haven't done big, comprehensive overhaul work on our mental health system" since the Mental Health Services Act 20 years ago, said Sen. Susan Eggman, California District 5 state senator. Eggman continued, "There was an understanding [in 2004] that we're going to deinstitutionalize people, but at the same time, we're going to provide a rich, community-based model of care, which never quite came to materialize."

San Francisco is certainly not the only city impacted by a homeless population. However, the problem has become a flashpoint for the City by the Bay. In the last year, several pieces of legislation passed in California to address three issues: homelessness, mental healthcare and substance abuse.

Click on each piece of legislation for more information.

Unlike many places in the state, the city and county of San Francisco has embraced the legislative change. Many feel these measures are the best, and maybe the only, way to dig the city out of the hole it’s found itself in.

In a written press release, San Francisco Supervisor Rafael Mandelman said Prop 1 created a "once-in-a-generation opportunity." The release also said he would continue to work towards securing resources "to get severely mentally ill San Franciscans off the streets and into care" and that San Francisco is "planning to be ready" to implement Prop 1.

Additionally, San Francisco became the first and only county in California to adopt the aggressive Senate Bill 43 changes to conservatorship laws, according to that release. Since the city established the change, the number of people petitioning for conservatorship, or a court appointment to take over the care and finances of an incompetent adult, increased by 170% over last year.

California has a long and spotted history with institutionalization going back to the Victorian era. Post-1950s, mental healthcare evolved. Mental healthcare has become even more normalized in the past decade, with about 20% of American adults in 2022 experiencing mental illness and 5% experiencing severe mental illness, according to Mental Health America. Institutionalization fell out of favor and community-based systems grew in popularity.

In this vein, programs like the CARE Act, which assigns treatment plans to people with schizo spectrum disorders, are meant to address the needs of mentally ill Californians without locking them up for good, said Eggman.

"We know that while the habits and the practices of institutionalization were bad, there were some aspects of it that I don't think people accounted for when they made the changes," Eggman said. "Like housing, like income, like food, like monitoring folks who, for whatever reasons, may need ongoing support."

Eggman used an interesting phrase when she talked to me: "dying with their rights on" — as in, people granted the right to refuse support, including medical treatment, who end up dying in the streets. Eggman credits Dr. Susan Parvoti, a psychiatrist and medical director of Homeless Health Care Los Angeles, with coining the phrase.

I struggled with this. Obviously, it's not alright for the government to let people die in the streets. But — at the risk of sounding patriotic — as adult Americans, don't we have the right to control our own bodies? If we don't want help, should our government strongarm us into accepting it?

It's not a problem for me. I'm medicated and stable. I'm educated, not homeless and not a substance abuser. I'm white.

After my short stint in the hospital, I found a psychiatrist who was able to help me get on helpful meds. Since then, I've gone to college and then grad school; I've held down jobs. My story is a success story — a "look what she overcame" story.

Not everyone is as lucky as me. There are many people without my privileges that cannot say this legislation doesn't affect them.

Who does this actually impact?

"Well, the population that's most challenging in terms of homelessness and in terms of substance abuse, particularly chronic homelessness, are those who are afflicted with mental illness, in particular severe mental illness, [such as] schizophrenia and schizophrenia-like conditions," said Sen. Thomas Umberg. He's the other state senator, besides Eggman, who proposed CARE. "We've devoted a lot of time, effort and treasure to dealing with this problem."

That’s one perspective. Dr. Helen Hsu has another.

It's an overcast day at Stanford University. Hsu, of Stanford's counseling and psychological services, invited me into her office. It's littered with plants reaching for the window behind her desk and dotted with textured throw pillows — so patients have something to fiddle with as they talk, she told me.

Hsu thought the insistence on lumping together homelessness, substance abuse and mental health was disingenuous.

"They're conflating issues that are a Venn diagram — related but distinct," said Hsu. "There are many reasons we have a homelessness crisis that actually have nothing to do with mental health … Not everyone with a substance abuse condition has a mental health condition. Many do, but not everybody. Certainly not everybody with a mental health condition is homeless or uses any illicit substances."

There is a perception that all homeless people have severe mental illness and/or are abusing illegal substances, as Umberg indicated and Hsu refuted. In a 2023 study, the Substance Abuse and Mental Health Services Administration found that about one fifth of homeless people have severe mental illness and 16% have substance abuse disorders. That’s higher than the national average, but nowhere near being the majority of cases.

Dr. Helen Hsu on internalized stigma about being mentally ill. (Photo by Marie Louise Leone) [TRANSCRIPT]

"It is a very painful time for anyone who's paying attention when there's multiple wars and exploitation going on. In the area of mental health, what I really tried to teach students is to understand that at this point, we have treatments available for many things and many types of treatments. So again, the lack of portrayal and accurate portrayal has people thinking that, 'I'm going to be in treatment forever, I'll be locked up, they're going to do electroshock therapy on me,' et cetera. And it's like, you know, actually let's talk about your options. Not everyone needs meds, absolutely not. And then there are many different types of therapy, and you can figure out which one is best for you. If you don't like your first couple therapists, and it's a bad fit culturally, or whatever, find a new one. Ableism goes for people with visible but also invisible disabilities. And so there's a lot of misinformation or presumptions about 'what does it mean,' if somebody has a mental health disability or condition, this idea that if you have a mental illness, you are somehow weak, or maybe you are dangerous, those kinds of misunderstandings."

Does this matter? If we're talking about taking people's rights away, Hsu argued, it's worrisome to throw such a wide net.

"The concern of those who support those living with mental illness is, almost like the Britney Spears effect, are you taking away our rights, supposedly for our own good?" Hsu said. "Instead of giving them more options for prevention, and more choices about what is the best way to handle this, because recovery is really different for every person; there really isn't only one answer. Removing people's rights is always a very slippery slope."

Devil's advocate! It's true people with severe mental illnesses may be victims of abuse, but often their family genuinely wants the best for them and they aren't in a position to recognize it. Psychosis, after all, is characterized by a break from reality. If the reality of the situation is that a mentally ill person needs help but can't acknowledge it, it may feel like family's responsibility to get them the treatment they need.

"That's very understandable, and in other countries, family is much more involved than in this country, which prizes individualism," said Hsu. She frowned over her mask. "However, we're also not that many decades removed from when a family member could just accuse someone of being ill, have them locked up and then divorce them."

The mentally ill will always be among us; the drug addicts and the poor, too. There's always that fear lurking in the back of my mind as I interview these doctors and politicians. Being institutionalized is every crazy person's worst nightmare — or second-worse, after lobotomy.

Umberg acknowledged that there was no quick fix. "I think that there are always going to be folks with mental illness," he said. "I think there's always going to be a need for government structured intervention in terms of mental illness and homelessness."

He continued: "Do I think that this [CARE Act] is an idea, a program, a project and an initiative that can make a difference in some families' lives? In some individuals' lives? Absolutely."

It's going to make a difference in people's lives. All of this legislation will. It'll help some people; it'll harm others. Whether it does more harm than good is something that voters and taxpayers have now ensured we'll find out.

In the meantime, I'm continuing to take my meds. In the current political climate, I don't feel it's a great idea to be openly insane on the streets of California.