Emptying state institutions was supposed to help fix mental health care. What happened?

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Nick Johnston worked during the 1960s at a massive psychiatric hospital in Illinois. He remembers one of his first patients telling him that her husband used political connections to have her wrongfully locked away.

Such abuses were part of the complicated and sometimes shameful legacy of state institutions for people with mental illness across the country. And they were part of the reason Johnston — who later led a St. Cloud outpatient mental health center — has long supported the push to develop community-based alternatives to institutions.

But patient advocates say the system for community care — from group psychotherapy to live-in treatment centers — was never fully built in Minnesota or throughout the U.S. It prompted Johnston to ask Curious Minnesota, the Star Tribune's reader-powered reporting project, whether this was partly because state funding wasn't reinvested as Minnesota's institutions closed.

"How much of the money saved," he asked, "was used for the creation and operation of community mental health centers and services?"

The precise answer to that question is tricky because the story of de-institutionalization spanned many decades, so any savings didn't happen all at once. What is clear, though, is that closing institutions didn't free up enough state money to create a fully functional community-based system, said Tony Lourey, a former DFL lawmaker and one-time commissioner of the Minnesota Department of Human Services.

The federal government promised money beginning in the 1960s to create a network of new community mental health centers, but funds got tight even before the support was effectively slashed during the 1980s, said Sue Abderholden, executive director of the patient advocacy group NAMI Minnesota. Critical gaps in non-hospital care remain today, Abderholden said, even though more state and federal funding over the past 25 years has moved the community-based system closer to the goal.

"We are spending a lot more and we are providing a lot more services," she said, "but we are still not meeting the need."

Institutions draw scrutiny

Minnesota established its first public hospital for people with mental illness in St. Peter in 1866. As the population grew, several other hospitals were added, including facilities in Rochester, Fergus Falls, Hastings and Anoka.

The building that housed Fergus Falls State Hospital is still standing, a massive structure spanning a third of a mile. For decades, it was a largely self-sufficient microeconomy, with farm operations that fed the 1,600 to 1,800 patients who lived there, said Chris Schuelke, executive director of the Otter Tail County Historical Society. The patient population peaked at about 2,000 during the Great Depression and shifted over time to include many with developmental disabilities.

"It's immense," Schuelke said of the building.

The years following World War II were controversial for the facilities. The Minneapolis Tribune published a blistering exposé of poor living conditions in 1948. Gov. Luther Youngdahl made a high-profile push for change, including a 1949 media event where he burned straitjackets, leather straps and other devices that had been used to restrain patients at the state hospital in Anoka.

"His goal was to move Minnesota's mental institutions from among the worst in the nation to a model for the future," wrote Susan Foote, a retired University of Minnesota public health professor, in her book "The Crusade for Forgotten Souls."

The push for reforms drove significant improvements, Foote said in an interview. But some didn't endure beyond Youngdahl's time in office.

In 1963, President John F. Kennedy described his vision for a better mental health care system based on care in community facilities, rather than institutions. It built on the successful introduction of the first antipsychotic medications during the mid-1950s, which already were letting many patients with serious mental illness live outside state hospitals.

With passage of the Community Mental Health Act, the federal government started providing $150 million for construction and staffing of 1,500 community mental health centers. Each facility was meant to serve regions with between 75,000 and 200,000 people, providing inpatient and outpatient services, day treatment, emergency care and ongoing consultation for patients. The hope was the entire country would be covered by the mid-1970s.

"The mentally ill ... need no longer be alien to our affections or beyond the help of our communities," Kennedy said after signing the law.

On the streets and in jails

The legislation accelerated de-institutionalization across the country. In Minnesota, state hospitals that once treated more than 10,000 patients with mental illness had roughly 3,000 by 1970.

The community mental health centers were going to be one-stop shops that would provide everything from clinic care to crisis services, Abderholden said. But federal funding cuts meant only half the centers were ever built, she said. Plus, there was an evolving understanding of what services would be needed and how much it would cost, said Dr. Paul Goering, a psychiatrist and former physician executive at Allina Health.

Foote recalled interviewing former staff at Fergus Falls who described watching long-term patients being discharged into the community.

"One of them cried and said: 'We knew these people — we knew them really well. ... And we knew we were sending them to a place that was not going to work for them,'" she said. "On the other hand ... there is a lot of anger toward the institutions as they existed."

Homelessness accelerated in the 1970s, as many former state hospital patients returned to communities and couldn't find support, wrote Dr. Thomas Insel, the former director of the National Institute of Mental Health, in his 2022 book, "Healing: Our Path from Mental Illness to Mental Health." Insel described how jails and prisons over a 30-year period came to became "de facto mental hospitals."

In Minnesota, Hastings State Hospital shut down in 1978. The Rochester facility closed in 1982 while Fergus Falls stopped seeing patients in 2005. A search of documents at the Minnesota Legislative Reference Library did not find a report on what became of the systemwide savings across all state hospital closings. The long wind-down likely made this kind of analysis more difficult. Litigation from patients also drove the closures.

As the state was shutting down these large facilities, Goering noted, some smaller regional facilities opened in their place. A number of these have now closed, further complicating the math around savings and reinvestment.

Access problems endure

Today, patients still can have trouble finding the mental health care they need in Minnesota.

Growing demand for behavioral and mental health care since the pandemic has stressed the limited supply of caregivers — especially for Minnesota kids. Minnesota regulators say that health insurers have violated laws requiring consistency in coverage between mental and physical health care services. And patients confronting any supply and insurance barriers often stop seeking care.

One of the most obvious symptoms of limited access to basic and preventive mental health services is that too many patients in crisis keep landing in emergency rooms, where they can wait days to access one of the few mental health beds in general hospitals.

On the surface, it might look like this problem could be addressed by re-opening state hospitals. But patient advocates say this ignores the fraught history of the institutions, where abuse was abetted by isolating people with mental illness from their communities.

Goering, the psychiatrist, said the goal should instead be to keep working toward community-based care's unrealized promise. He pointed to expanded federal funding in late 2020 for Certified Community Behavioral Health Centers — a relatively new group of clinics that, in some ways, hark back to Kennedy's ideal.

Patients with serious mental illness who live in a supportive environment and are engaged with meaningful work or pursuits during the day, he said, can thrive with access to a full spectrum of mental health services. Those services could include drop-in centers, one-on-one therapy and timely access to medication management.

This care can largely prevent the need for a hospital bed for many patients, Goering said.

"Imagining a better future, instead of pointing fingers at imperfect actions in the past, feels more hopeful to me," Goering said, "and puts an achievable challenge out there for us, collectively."

Johnston, the retired St. Cloud mental health professional who sent this question to Curious Minnesota, sees community care as a much better option than a return to the state hospitals. The story of de-institutionalization has been a long and winding road, he said. But it doesn't make sense to veer backward.

"The institutions were easy to get into," he said, "and hard to get out of."

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