Right to be rescued?

Calvin Clark hovered above the swirling Columbia River from his tenuous perch on the interstate bridge nearly 140 feet above the icy currents. Calvin didn’t realize that his bipolar mania had him in a stranglehold as he considered slicing the water’s surface and letting himself slip into its frigid depths. In fact, he didn’t grasp that he was sick at all.

Only days before, law enforcement apprehended him ambling through traffic in Vancouver, Wash., rambling about igniting himself on fire or getting hit by a car. But the state didn’t have any psychiatric beds available, his mother recalled, so they drove him across the river and dropped him off at an Oregon hospital.

Staff held him there for five days—the maximum amount of time for an initial psychiatric hold in Oregon—and didn’t file commitment paperwork to keep him hospitalized longer. They discharged him into an Uber. The driver dropped him off at a homeless shelter where he spent one night before walking out onto the bridge. It was January 2017, when the Columbia River’s temperature hovered around 35 degrees.

He stood above the swirling water for a few moments, and then he jumped.

But not even his bipolar-induced mania could compete with the powerful instinct to swim formed from years of surfing and drilling with his swim team. It kicked in the instant he hit the water. Washington first responders rescued Calvin as he crawled up the river’s muddy banks. He was admitted to another hospital shortly after.

“We knew he was that sick, and had been trying to get him hospitalized in the weeks leading up to that suicide attempt,” his mother, Jerri Clark, recalled. “But he didn’t meet criteria until he actually tried to take his own life.”

Clark is a slight woman with short golden hair that curls around her chin. An unmistakable tenacity runs through the grooves creasing her forehead forged from years of battling a disease—and a system—alongside her son. Washington’s mental health law, like that in most states, permits involuntary hospitalization only if the individual is at substantial risk of inflicting serious harm on himself or others.

“In other words, treatment isn’t accessible until there’s a victim,” said Clark, who’s thrown herself into advocating for mothers and families fighting to access treatment for their loved ones.

America’s mental healthcare system routinely fails the severely mentally ill, especially those, like Calvin, who don’t understand that they’re sick—people who need care that extends beyond a few days in the hospital. Lawmakers in a growing number of states, including liberal bastions such as California and New York, are recognizing that. They’re pushing to relax involuntary commitment laws and overhaul federal funding regulations that limit in-patient treatment. But critics say that won’t solve the real problem: There’s almost nowhere for people who need ongoing care to go.

Jerri Clark sits on a park bench across from the neighborhood playground that her son Calvin used to play on near her home in Vancouver, Wash. Photo by Sy Bean

MENTAL HEALTHCARE in the United States changed radically between the 1960s and 1980s. The introduction of chlorpromazine, one of the first antipsychotic medications, coupled with concerns about mistreatment and abuse within long-term mental hospitals and asylums contributed to a push for community-based outpatient treatment. Reformers believed new medications would enable the severely mentally ill to live relatively normal lives and integrate back into society.

But the wide-scale closures of psychiatric hospitals—a phenomenon that became known as deinstitutionalization—­had even more to do with Congress’ fierce debate over the Medicare and Medicaid Act of 1965. Lawmakers worried states would shift the massive cost of specialty psychiatric hospitals to the federal government, imperiling the program’s long-term financial stability. So, lawmakers prohibited Medicaid from paying for stays in psychiatric facilities with more than 16 beds. They called it the Institutions for Mental Diseases exclusion. It encouraged states to move elderly psychiatric patients into more cost-effective nursing homes and treat other patients in general hos­pital psychiatric units or community outpatient clinics.

In 1967, California enacted the Lanterman-Petris-Short (LPS) Act, paving the way for other states to tighten civil commitment standards. The law ended indefinite involuntary commitment and established the imminent danger and grave disability standards that are now the norm across most of the United States. To qualify for civil commitment, a patient must be an imminent danger to himself or others or be unable to care for basic personal needs.

By the end of the 1970s, nearly every state had established civil commitment requirements similar to the dangerousness standards outlined in California’s LPS law.

As state psychiatric hospitals shuttered, the number of psychiatric beds dwindled from more than 550,000 in 1955 to below 200,000 in 1975. By 2017, that number had dropped to 170,200, including private hospitals, general psychiatric units, Veterans Affairs medical centers, and other 24-hour residential treatment centers. But psychiatric beds in state and county facilities totaled just 37,209. Forensic patients—those who committed a crime and are waiting to stand trial—occupied nearly half of state hospital beds in 2016.

In 1974, Wisconsin psychiatrist Darold A. Treffert published a letter critiquing the deinstitutionalization movement in which he coined the phrase “dying with their rights on.” On the second page, a large black skull clutches a rolled up Bill of Rights in its gaping jaw.

“We are struggling now to come to some reasonable middle ground between the right to be ill and the right to be rescued,” Treffert wrote. “The ­pendulum now threatens to reach the other extreme.”

Calvin Clark attended Willamette University in Salem, Ore., on a speech and debate scholarship. He earned straight A’s in high school, according to his mom, and won a state championship in extemporaneous speech. “He was extremely bright, very independent, very organized, very loving, very perceptive,” Jerri Clark told me. “He always recognized when somebody else needed a little word of encouragement or a little kindness.”

Calvin joined an honors program in college and, at first, seemed to be thriving in his new academic setting. But one day, Clark answered a call from the 19-year-old freshman, who sounded distressed, confused, and even paranoid. He told her his debate team had ostracized him, that everyone he knew was turning against him, that he wasn’t safe. His parents picked him up and brought him back to their two-story suburban home.

“That night, he was ripping around the house, crying about demons that had taken over our home,” Clark recalled. Calvin locked one of the downstairs bathrooms to keep his family members out, claiming it was full of demons. He spoke in disjointed word salads. That’s when his mother realized he was in full blown mania.

A primary care doctor diagnosed her son with bipolar I with psychotic features, a condition that causes its victim to oscillate between episodes of severe depression and bursts of mania, periods of abnormal energy. The Clarks connected with a psychiatrist who prescribed Calvin antipsychotic medications. But his commitment to the medications “waxed and waned,” Clark said. The medications blocked the overproduction of dopamine that contributed to his bouts of mania, but they also flattened his emotions and dulled his senses. He hated the way they made him feel.

And when he didn’t take them, Calvin wasn’t able to recognize that he was sick. It’s a condition known as anosognosia, or a lack of insight into one’s mental illness. “He had no ability to know that what was really going wrong was in his own head,” Clark said.

Clark holds a photo of Calvin deep-sea swimming with a pod of dolphins in Hawaii. Photo by Sy Bean

ANOSOGNOSIA IS PART OF THE REASON why the severely mentally ill are disproportionately represented among the homeless and behind bars in county jails. Roughly 25% to 35% of the homeless population has a severe mental illness. About 44% of people in jail have a history of mental illness, according to the National Alliance on Mental Illness (NAMI).

“​​They’re going from the street to the hospital to the jail, the street back to the hospital, back to jail … in what we call the revolving door,” said Mark Gale, a NAMI volunteer in Los Angeles and the former criminal justice chair for NAMI California. Gale watched his own son cycle through that revolving door.

Residents of coastal Democratic states with burgeoning homeless populations have had enough of passing people wasting away on subways or street corners. New York residents have witnessed several high-profile instances of mentally ill individuals committing horrendous acts of violence during the past few years. “For people in major cities like New York, Los Angeles, and San Francisco, the failures of the mental health system are very easy to see,” said Carolyn Gorman, a policy analyst at the Manhattan Institute.

Lawmakers in these traditionally liberal strongholds are listening. Earlier this year, Kathy Hochul, the Democratic governor of New York, pressed lawmakers to add a grave disability provision to the state’s mental health law. It would allow authorities to intervene when people are unable to meet their basic needs such as food, shelter, and medical care. State law previously limited intervention to overt violence and suicidality. Despite initial resistance, legislators agreed to include the change as they wrapped up their budget negotiations for the next fiscal year. Nearly 90% of New Yorkers support the change, the Association for a Better New York found in a recent poll.

Oregon lawmakers are also weighing changes. “I think there’s a recognition that deinstitutionalization, as a policy, did not go as planned,” Gorman said. “And [that] reasonable involuntary commitment is more compassionate than just leaving people to deteriorate on the streets.”

Alex Barnard, a researcher and assistant sociology professor at New York University, cataloged the number of mental health bills states introduced between 2011 and 2022. He discovered lawmakers put forward twice as many proposals between 2021 and 2022 compared with 2011 to 2012.

In October 2023, California Gov. Gavin Newsom signed a bill expanding the state’s definition of “gravely disabled.” The changes added an inability to provide for personal safety or essential medical care to the list of reasons why someone could be involuntarily committed to a hospital. The law now also includes individuals suffering from a severe substance use disorder and co-­occurring mental health disorder.

That same month, the Golden State launched a program called Community, Assistance, Recovery, and Empower­ment (CARE) Court. The program aims to connect those struggling with a severe mental illness or substance abuse disorder with treatment before they spiral enough to qualify for involuntary commitment. It gives a broader group of people the ability to petition a court on behalf of a mentally ill individual. Parents. First responders. Hospital directors. Roommates. If a judge determines someone qualifies for CARE Court, a behavioral health specialist helps formulate a court-ordered treatment plan.

At the federal level, President Donald Trump appears to support a shift toward mandating treatment more frequently. Trump released a campaign video in which he decried rampant street homelessness plaguing American cities, fueled by untreated mental illness and substance abuse. He laid out a vision of large parcels of inexpensive land where the homeless could congregate and get access to the treatment they need.

“For those who are just temporarily down on their luck, we will work to help them quickly reintegrate into a normal life,” Trump said. “And for those who are severely mentally ill and deeply disturbed, we will bring them back to mental institutions, where they belong, with the goal of reintegrating them back into society once they are well enough to manage.”

At the end of July, the president issued an executive order aimed at making it easier—through technical assistance, grants, and other means—for state and local governments to involuntarily commit individuals “who pose risks to themselves or the public or are living on the streets and cannot care for themselves.” The administration will also seek the end of consent decrees and other court orders or policies that impede civil commitment, Trump’s order reads.

JERRI CLARK WONDERS what might have been different for Calvin if he had received the same kind of treatment as her father-in-law. Doctors also diagnosed him with a severe bipolar disorder that included psychotic features. Despite multiple suicide attempts, he got his condition under control thanks to a long period of hospitalization at the beginning of his illness and consistent medication, Clark said. He lived a relatively normal life for more than 50 years. “That level of treatment wasn’t available to Calvin,” she said.

Instead, he ended up homeless. Multiple times. “Living in our house became unworkable because he was so unwell,” Clark said.

Calvin wound up homeless for the first time shortly after he embarked on a quest to California to find himself and find God. He joined a commune rife with marijuana use. The drug contributed to another psychotic break and another brief hospitalization, this time in the Golden State. Eventually, Calvin moved back to Seattle, relatively stable after his hospital stay and consistent medication. He joined a program at a youth shelter in the city and found employment. His parents rented him a room in the city. But it didn’t last long.

The housing came with care management and outreach services, but Calvin still had to show up for his appointments. He still had to follow through on taking his medication. Often, he didn’t. All too soon, he lost his job and his housing and quit his treatment plan.

Calvin ended up homeless again and eventually incarcerated.

After his bouts of homelessness and jail stays, Calvin qualified for a Washington program called Assertive Community Treatment, which provides more robust case management, though the mentally ill individual must still consent to participate. Clark believes Calvin’s illness was too out of control for a program like that to be successful.

“What he needed was a long-term stay in a state hospital, like what his grandfather got, long enough to get the medication regimen really clear,” said Clark, who now serves as the resource and advocacy manager for the Treatment Advocacy Center, a group pushing to reform state hospitalization laws to make it easier to treat and, if necessary, involuntary hospitalize the severely mentally ill. “What we have in almost all of our states now is a catch and release hospitalization program. We catch somebody in their worst, worst, worst stage of illness, give them enough medication that they can make a tiny bit of sense, and then we toss them back out into the world.”

Memorabilia of Calvin Clark Photo by Sy Bean

CRITICS OF STATE-LEVEL PUSHES to reform involuntary commitment laws argue they don’t go far enough, or misidentify the root problem entirely.

Gale, the NAMI volunteer in Los Angeles, said part of the problem is that lawmakers keep trying to target individuals who won’t accept treatment voluntarily with more voluntary programs. Though California’s CARE Court program is technically a court-ordered treatment plan, participants can still opt out at any time, with no civil or criminal penalties for refusing to participate. “The number of graduates, you can count on your hands so far,” he said. “It’s not a success.” He’s more optimistic about the state’s changes to its grave disability standard to include personal safety and essential medical treatment. Los Angeles County will begin implementing the new standard for involuntary commitment starting Jan. 1, 2026.

Gorman, the Manhattan Institute fellow from New York, pointed out that efforts to hospitalize more people will keep hitting a wall of bed shortages unless states find a way around the Medicaid Institutions for Mental Diseases (IMD) exclusion that prohibits Medicaid from paying for facilities with more than 16 beds. The severely mentally ill and their families rely heavily on Medicaid to afford treatment. The program pays more than any other insurance company to care for the severely mentally ill.

A bill introduced in Congress last year sought to expand the number of eligible beds from 16 to 36. Completely eliminating the exclusion would have increased federal costs by $38.4 billion between 2023 and 2024, according to Congressional Budget Office estimates.

But Alex Barnard, the sociology professor at New York University, isn’t convinced that easier hospitalizations or even reversing the IMD exclusion will stanch the leaks in the system. Just ask him about his brother.

Barnard’s brother grew up with significant developmental disabilities. Then, in early adolescence, he started exhibiting symptoms of bipolar disorder with psychosis. A frightening new symptom emerged in his early 20s: an unresponsive, psychotic state called catatonia. “You just pace,” Barnard said. “You just walk for days. It’s both an incredible but very disturbing thing to see.”

Involuntary treatment was essential for his brother. Without intensive therapy, a patient with catatonia might starve themselves to death and slowly slip away. But at the same time, Barnard is wary of characterizing lengthy hospitalizations as a “magic bullet treatment.”

“I think families are often being a little bit sold a false bill of goods,” he said. Groups like the Treatment Advocacy Center routinely blame strict commitment laws for preventing a loved one from receiving care in time. But despite relentless critiques of its strict civil commitment standards, California still has one of the highest rates of involuntary hospitalization, Barnard noted.

It’s what happens after someone’s discharged that counts, he argued, and states desperately need long-term, dignified residential care and housing support for people who maybe won’t ever achieve a normal life. Barnard believes eliminating the IMD exclusion means hospitals will absorb more of our limited mental health dollars, money that could be invested in more economical supportive housing options for people transitioning out of locked hospital settings.

Today, Barnard’s brother, who recently turned 40, lives in his own apartment and works a job. That’s only possible because of the intensive support he receives in Minnesota due to his developmental disabilities, not his mental illness. Staff check in on him daily and a psych nurse visits him once a week. “He’s killing it,” Barnard said with a wide smile. “He’s doing amazing.”

CALVIN CLARK NEVER FOUND that kind of lasting stability during the four years of his illness.

While living in Seattle, he got involved with an organization that supports people in recovery from severe mental illness. “Everybody loved him right away,” Clark recalled. “They wanted him to kind of be a spokesman.” When Calvin masked his symptoms, he was confident, smart. A magnet. The group sponsored him to attend a conference in St. Louis.

While there, he stopped taking his medication. Then, he jumped off the hotel roof. A doctor called Clark from a St. Louis hospital to tell her what happened. Her son died on March 18, 2019.

They held his funeral at a community center overlooking a lake where the family had enjoyed stand-up paddleboarding together. Clark’s brother put together a video montage of Calvin’s life. Clark herself spoke about the injustices she had witnessed navigating a broken treatment system. Songs by the surfer band Switchfoot played in the background. “It was a beautiful celebration of a life that should have lasted a lot longer,” she said.