The Way Out

Summary

Lost Patients: Episode 5 - "The Way Out"

Introduction

In the fifth episode of Lost Patients, titled "The Way Out," KUOW News and Information delves deep into the labyrinthine mental healthcare system in America through the tragic story of Adam Ornd. The episode explores the systemic failures that contribute to the loss of patients with severe mental illness, ultimately leading to Adam's untimely death. Through real-life testimonials and investigative reporting, the series sheds light on the cyclical challenges faced by individuals navigating mental health services in Seattle and Washington State.

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Adam's Struggle with Mental Illness

The episode centers on Adam Ornd, a nearly 40-year-old man battling severe mental health conditions, including schizophrenia, schizoaffective disorder, and bipolar disorder. Adam's journey is marked by instability as he oscillates between emergency rooms, psychiatric hospitals, jails, and homelessness.

• Heidi Urand's Hopeful Moment (00:00-02:27)

  In 2022, after six months of no contact, Adam sends his mother, Heidi Urand, a Mother's Day card from Western State Hospital, Washington's largest remaining psychiatric facility. Heidi expresses hope upon seeing the card's return address:

  Heidi Urand (00:19): "Adam sent me a Mother's Day card, and he had not done that in years. I mean, really a long time. And it was exciting because we hadn't heard from him."

  This moment signifies a potential turning point, suggesting that Adam might finally receive the comprehensive care he desperately needs.

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Western State Hospital: A Rare Beacon of Hope

Western State Hospital, with approximately 800 beds, stands as one of the few large psychiatric institutions in the U.S., especially after the wave of deinstitutionalization in the 1970s. Despite its capacity, the hospital struggles to maintain adequate care due to the intertwined nature of the criminal legal system and mental health services.

• Institutional Overview (05:55-07:53)

  The hospital often becomes a holding facility for individuals with mental illness who are entangled in the criminal justice system. Despite the provision of services like competency restoration, which aims to stabilize patients for legal proceedings, these services fall short of genuine mental health care.

  Esme Jimenez (07:26): "What that typically looks like at Western State Hospital is a lot of classes where they say, like, here's what a judge does..."

  This approach highlights the system's focus on legal compliance rather than therapeutic intervention.

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The Discharge Process and Its Failures

After ten months at Western State Hospital, Adam is discharged back into homelessness. This decision, driven by criteria that deemed him no longer in need of involuntary treatment, sets the stage for his eventual overdose and death.

• Decision to Discharge (11:03-14:49)

  Aaron Gadue, overseeing the discharge process, explains the stringent criteria for continued commitment under Washington's Involuntary Treatment Act:

  Aaron Gadue (12:35): "If they're no longer requiring active treatment, it's unethical for us to continue to keep them detained at a facility for any longer than they should be."

  However, the episode reveals that Adam's discharge was also influenced by incomplete or missing medical records, leading to an oversight of his severe mental health needs.

  Esme Jimenez (12:59): "When I look at his discharge paperwork, I see that there's a bunch of substance use disorders outlined there... however, there's no actual diagnosis on the mental health side of things."

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Challenges in Securing Housing and Support

The episode underscores the scarcity of affordable and appropriate housing options for individuals with severe mental illness. Social workers struggle to place patients in supportive environments due to limited resources and bureaucratic limitations.

• Housing Scarcity (16:06-20:25)

  The deinstitutionalization era's promise of community-based care remains unfulfilled, leaving social workers to navigate a fragmented landscape of supportive housing with dwindling options.

  Aaron Gadue (18:06): "So it is very much word of mouth. Our social workers are cold calling and sweet talking and trying to do whatever we can to kind of wheel and deal with."

  This environment forces patients like Adam to face homelessness upon discharge, with few safeguards in place to prevent relapse or crisis.

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Family's Desperate Efforts to Reconnect

Heidi Urand and her daughter Bethany Anderson embark on a relentless quest to locate and help Adam after his discharge. Their efforts reveal both the system's shortcomings and the profound personal toll on families.

• Heidi's Vigilance (28:13-42:09)

  Unable to secure a place for Adam within institutional frameworks, Heidi employs unconventional methods, such as monitoring street cameras, to find her son. Her dedication culminates in a heartbreaking encounter:

  Heidi Urand (35:40): "I saw him. I said, Adam, get in the car. And I don't know if he recognized me or not, but he got in the car."

  Despite her efforts, Adam resists returning home, highlighting the complex interplay between personal agency and systemic failure.

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The Tragic Conclusion: Overdose and Death

Less than a month after his discharge, Adam overdoses on fentanyl, leading to his death. The episode poignantly captures the culmination of systemic neglect and the personal anguish of his family.

• Final Moments (43:44-47:15)

  Derek Derricks, a Seattle resident, recounts witnessing Adam's overdose:

  Derek Derricks (43:02): "He was just kind of, like, laying there flat on the ground... I saw them pretty much wrap it up, like, wrap them up and put them in the paramedics truck."

  Concurrently, Bethany describes the shock and grief her mother experiences upon learning of Adam's death:

  Bethany Anderson (44:33): "I was so angry at my brother, but at the same time, I was glad he wasn't in pain anymore."

  The family's attempts to donate Adam's organs are thwarted by the extensive damage caused by his time on the streets.

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Systemic Reflections and Conclusions

The episode concludes with a critical analysis of the mental healthcare system, emphasizing that Adam's story, while deeply personal, reflects broader systemic issues.

• Esme Jimenez's Insights (47:43-50:30)

  Esme articulates that the failure isn't isolated to individual actors but is embedded in the system's very design:

  Esme Jimenez (49:26): "Technically, everything worked, right?... The issue was that there was nothing else beyond that. So when you're looking at actually stabilizing a person like Adam..., there's nothing that does that in our current setup."

  This perspective challenges the notion of a "broken system," suggesting instead that the existing framework inherently fails to provide comprehensive, lifelong support for the most vulnerable individuals.

• Heidi's Adam's Legacy (51:31-51:44)

  Heidi poignantly states:

  Heidi Urand (51:44): "This is not a one person failure. We all failed Adam, somehow or another."

  This statement serves as a call to action, urging society to rethink and redesign mental healthcare to prevent similar tragedies.

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Final Thoughts

"The Way Out" of Lost Patients offers a harrowing glimpse into the complexities and failings of the mental healthcare system in America. Through Adam's story, the episode highlights the urgent need for systemic reform, emphasizing that without a cohesive, supportive infrastructure, individuals with severe mental illness remain vulnerable to cycles of institutionalization and homelessness. The heartfelt narratives of Adam's family underscore the profound human cost of these systemic inadequacies, making a compelling case for comprehensive, compassionate mental health care.

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Notable Quotes with Timestamps

• Heidi Urand (00:19): "Adam sent me a Mother's Day card, and he had not done that in years. I mean, really a long time. And it was exciting because we hadn't heard from him."

• Esme Jimenez (07:26): "What that typically looks like at Western State Hospital is a lot of classes where they say, like, here's what a judge does..."

• Aaron Gadue (12:35): "If they're no longer requiring active treatment, it's unethical for us to continue to keep them detained at a facility for any longer than they should be."

• Aaron Gadue (18:06): "So it is very much word of mouth. Our social workers are cold calling and sweet talking and trying to do whatever we can to kind of wheel and deal with."

• Heidi Urand (35:40): "I saw him. I said, Adam, get in the car. And I don't know if he recognized me or not, but he got in the car."

• Esme Jimenez (49:26): "Technically, everything worked, right?..."

• Heidi Urand (51:44): "This is not a one person failure. We all failed Adam, somehow or another."

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Conclusion

Lost Patients meticulously unravels the intricate web of challenges faced by individuals with severe mental illness, using Adam's tragic narrative as a poignant example. The episode serves as a powerful impetus for audiences to reflect on and advocate for meaningful changes in the mental healthcare system, ensuring that no other "Adam" falls through the cracks.

Transcript

[Will James]

Lost Patients is about serious mental illness. This episode involves drug overdose and death, so it might be disturbing for some listeners. Heidi Urand hadn't been in contact with her son Adam for about six months when a Mother's Day card appeared in her mailbox in 2022.

[Heidi Urand]

Adam sent me a Mother's Day card, and he had not done that in years. I mean, really a long time. And it was exciting because we hadn't heard from him.

[Will James]

Adam had diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, and a list of other mental health conditions. We met him back at the start of this series, and despite all these diagnoses, he had spent about seven years at that point, ricocheting among emergency rooms, psychiatric hospitals, jails, a stint in prison, and the streets in and around Seattle without ever really stabilizing. Contributing to that cycle were the drugs he used, including opioids and meth. Adam was almost 40 years old when Heidi got that Mother's Day card. She had spent years worrying about him, often not knowing where he was. It wasn't clear this churn was ever going to end. Then Heidi saw where the card was mailed from. Western State Hospital. Somehow, Adam had landed in Washington's largest remaining psychiatric hospital, one of the last places in the state that could hold and treat someone with serious mental illness for potentially years.

[Heidi Urand]

I was excited that maybe somebody was going to get to the bottom of the mental illness and help him.

[Will James]

After all the years of futility, Western State seemed different, an institution actually equipped to get a handle on Adam's problems and help him recover. When Heidi told her daughter, Adam's sister, Bethany Anderson, she celebrated.

[Bethany Anderson]

She told me, and I was like, that's awesome.

[Heidi Urand]

He must be okay.

[Bethany Anderson]

He must be okay. Here's my excitement.

[Unnamed Family Member]

Somebody must have him locked up.

[Esme Jimenez]

Yay.

[Bethany Anderson]

Because you're sending a card, I know you're alive at that point, but not just that.

[Heidi Urand]

Somehow you have the fortitude to do something that you haven't done in years, you know, so that means you might be okay.

[Will James]

Heidi would spend a long time trying to make sense of what happened next. Ten months after Adam arrived at the hospital, the state discharged him back onto the streets of Seattle, homeless and, according to Heidi, still showing signs of mental illness. Adam's life at that point had been a long chain of people making decisions about his care that were difficult for Heidi to comprehend. But the state's decision to release him to homelessness stood out among all the others. It would end up being the most consequential decision of Adam's life. That takes us back to the beginning of this series with Seattle Times reporter Esme Jimenez trying to understand why the state government would pluck someone out of homelessness, spend nearly a year treating him, and then drop him right back where he started. When Heidi first told her this story, Esme found it hard to believe.

[Esme Jimenez]

I just thought like, that cannot be possible. You cannot possibly be spending so much time and money on someone's recovery for a year nearly, and then just drop the ball there.

[Will James]

Esme thought if she could pinpoint where this process broke down for Adam, what exactly went wrong with his discharge, it might reveal something important about why so many seriously mentally ill people end up on the streets. But Esme's investigation would reveal something else to her entirely, a whole different way of thinking about what's wrong with psychiatric care. I'm Will James from KUOW and the Seattle Times. This is Lost Patience episode 5 the Way out the name on the return address on that Mother's Day card Western State Hospital means something to families of people with serious mental illness here in Washington. It's the state's oldest and largest psychiatric hospital. It started as a fort in the days before Washington was even a state. When deinstitutionalization swept the country and Northern State closed in 1973, Western State was one of two state psychiatric hospitals that survived here. It's down to around 800 beds now, but it's still one of the 10 biggest in the US after decades of failure to build community based care that effectively treats people with serious mental illness, many of those patients now decline until they get arrested. As a result, the state's remaining psychiatric hospitals and the crew criminal legal system have blurred together. Today, Washington's second largest state mental health institution after Western State is a prison with a 500 bed psychiatric unit. Meanwhile, Western State Hospital has transformed into an arm of the criminal legal system. Most of the people who end up there come from jail. Adam was one of them. To recap where we left off in Adam's story, he was serving a three year prison sentence for car theft. Heidi and Bethany felt some relief. He was in a secure place. Doctors in prison diagnosed Adam with schizophrenia and other serious mental illnesses, put him on suicide watch and tried to stabilize him with medication.

[Esme Jimenez]

During the three years in prison, he'll take his medication if he's bribed with peanut butter crackers. But when the peanut butter crackers are gone, he won't take his medication multiple times. That lands him back in the special offenders unit because he decompensates. He gets Worse, he stops sleeping. He does not shower. He cannot function.

[Will James]

While prisons and jails are now some of the biggest providers of mental health treatment in the country, Esme is not surprised Adam did not recover there.

[Esme Jimenez]

I've talked to social workers who work in jails, and they will be the first to say this is not a therapeutic environment. Maybe I can even convince them to take a pill. Maybe I can even convince them to stay and do talk therapy with me once every three weeks whenever we have availability. But inherently, this is not a place where they're going to be able to stabilize. Truly, it's a jail, right?

[Will James]

Adam was released from prison into homelessness at the height of the pandemic. Less than a year later, he showed up in criminal records again, this time for throwing an empty beer can at a police officer. In 2022, Adam joined the more than 2,000 people deemed too mentally ill to stand trial in Washington state that year. When waiting in jails, often for months, until beds opened up in state psychiatric hospitals. One of Western states main jobs today is to work through this backlog of people waiting in jails and provide what's called competency restoration, giving them just enough treatment that they can participate in their own criminal cases.

[Esme Jimenez]

What that typically looks like at Western State Hospital is a lot of classes where they say, like, here's what a judge does, here's what a public defender is. The goal, by and large, is, can you tell me who you are? Can you communicate with your public defender or your attorney? Are you not gonna be screaming during the court case? They might have delusions, they might talk to themselves, but they know who a lawyer is. They know how to say, thank you, judge, and they can participate in the criminal legal system.

[Will James]

Competency restoration is not mental health care. But sometimes a judge decides a patient needs more significant treatment, and the patient's charges are dropped and they move to a different part of the hospital for a longer term stay. This narrow, roundabout path is essentially the only way to get committed to Western State these days, and it's how Adam ends up there. After about seven years churning in and out of different institutions, he had made it into the one that might actually hold onto him. What do we know about Adam's time at Western State?

[Esme Jimenez]

We have a little bit of information. We know he had some altercations with some roommates. We know from his family that at some point he was on medication, and that stabilized him quite a bit. His sister says it felt like Adam came back, like she could talk to him and have a full conversation at that Point.

[Will James]

It had been years, really, since his family was able to talk with Adam in that way.

[Esme Jimenez]

Yeah, I mean, that. That was pretty special to them.

[Heidi Urand]

When he was on the medication at the mental hospital, I talked to Adam every day. Sometimes I talked to him twice.

[Unnamed Family Member]

Once the fog lifted.

[Bethany Anderson]

We were having normal conversations we used to have. I mean, his normal sense of humor, his calm demeanor was back. You could tell he was depressed. You could tell he didn't want to be there. But he was fine. There was no voices. At his worst, he would talk to the side like this, like this, like this, like this. And real deep. That wasn't happening. It was 100%, day and night.

[Heidi Urand]

It was. Adam was back. You know, he was. He was back.

[Will James]

Heidi and Bethany started to see the Adam they remembered who could effortlessly remodel a car, teach himself a musical instrument, train a dog without treats. Heidi and Bethany attribute this to the medication they say Adam was on. But at the same time, they noticed Adam getting better. They also noticed he didn't really seem to engage with staff at Western State.

[Esme Jimenez]

In talking to his mom. We know that he was often pacing the hallways. He wouldn't really participate in group activities, Would mostly say to himself, I know.

[Heidi Urand]

For a fact that Adam stayed away from everybody. What do you do every day? I walk the halls. He didn't engage unless he had to, to get points, to get to go outside because he wanted to be outside. People with mental illness, they're not stupid. They know how to manipulate the system. They know how to not look bad. Because who wants to be in a system and be looked at like crazy and all your rights are taken away from you?

[Bethany Anderson]

Who wants to be diagnosed schizophrenic?

[Will James]

His mom, his sister are noticing that he's sounding better. He's there for a good chunk of a year, about 10 months. What happens from there?

[Esme Jimenez]

So his mom and sister learn that he's going to be discharged.

[Will James]

Here was the first step toward figuring out why the state discharged Adam into homelessness, figuring out why he was discharged at all.

[Esme Jimenez]

One of the emails that I received was that. Here's what it says. It says, On January 6, 2023, the treating psychologist noted that Mr. Ornd did not meet commitment criteria and is completely asymptomatic. So effectively, Adam is not having the best judgment as to what choices he should make. Perhaps. But he's not gravely disabled. He's not hurting himself or others. Therefore, he doesn't meet the bar for civil commitment.

[Will James]

Adam was held at Western State as a civil patient under the state's Involuntary Treatment Act. Every 90 or 180 days, someone from the hospital had to go back to court and argue Adam was still either a danger to himself, a danger to others, a danger to someone's property, or gravely disabled. And at a certain point, they opted not to go back to court to try to renew Adam's commitment again.

[Aaron Gadue]

The decision to not refile for a continued commitment is based on the fact that the patient no longer requires active treatment.

[Will James]

Aaron Gadue oversees the discharge process for Western State Hospital and other state institutions in Washington. He's in charge of a team of social workers who figure out where someone goes next as they get ready to leave Western State. He said he couldn't talk about Adams specifically because of patient privacy rules, but he could speak to the process generally.

[Aaron Gadue]

If they're no longer requiring active treatment, it's unethical for us to continue to keep them detained at a facility for any longer than they should be.

[Will James]

Esme wanted to figure out how the state came to this conclusion that Adam no longer needed treatment. What she learned was that the people overseeing Adam's care at some point decided he did not have a serious mental illness at all.

[Esme Jimenez]

When I look at his discharge paperwork, I see that there's a bunch of substance use disorders outlined there, like marijuana, meth, opiates. However, there's no actual diagnosis on the mental health side of things.

[Will James]

This was despite all the diagnoses Adam got earlier from doctors in prison and elsewhere. Despite his history of erratic behavior, muttering to himself, talking about a light or computer inside of him saying he was God, all documented in medical and legal records. Despite his mom and sister saying he seemed to improve on medication, and despite his family history of schizophrenia via his grandfather. We don't know whether Western State staff had access to Adam's past medical and legal paperwork when they made this decision, but it's likely they were missing at least some of it.

[Aaron Gadue]

Accessing records is challenging. I'll be the first to say that our state hospitals and our systems are oftentimes we're still working off of paper charts. Different jails use different health records, even having patients transfer from one community psychiatric hospital to another. We oftentimes see the paper trail will end.

[Will James]

But Erin says with or without records, it's the state's job to look at the patient with fresh eyes and figure out what's going on.

[Aaron Gadue]

Sometimes those diagnoses change. Maybe initially it's looking one way. We're definitely seeing signs of schizophrenia or bipolar disorder, schizoaffective disorder, and after a period of 90 days, it could look totally different. I'm not a clinician, so I can't speak too far in depth, But I can say that drug induced psychosis is something that is very challenging. Methamphetamine use can look very similar to schizophrenia, and it can take a long period of time for patients to stabilize from that drug induced psychosis. And so that's where it's important for every team, every clinician to be given the autonomy to evaluate that.

[Will James]

So maybe it comes down to the blurriness of psychosis, how when it comes to serious mental illness, a doctor's subjective judgment determines the diagnosis. And throughout Adam's life, different doctors had come to wildly different conclusions. Or maybe, as Heidi believes, Adam avoided talking to hospital staff so successfully they never got a clear read on him. Either way, the state had decided it no longer had legal grounds to hold Adam against his will. Hospital staff offered him a chance to stay voluntarily until they found somewhere to house him. But he said no. He wanted out. So a clock started ticking to find a place for Adam out in the world. So now Esme had an answer about why the state decided to discharge Adam. The next question was, why discharge him into homelessness? She turned to Aaron Gadue, one of the state officials who signed off on this decision.

[Aaron Gadue]

Every discharge to a shelter actually requires a couple of levels of review, Extra review at the state hospitals, including my.

[Will James]

Own western state has about eight social workers whose job is lining up homes and follow up care for patients like Adam as they get ready to leave the hospital. Aaron oversees this process as his social workers navigate a world shaped by deinstitutionalization. That era when many state psychiatric hospitals shut down, but the promised replacement of community care and housing never fully materialized. Social workers I've talked to at different hospitals say they could once pretty reliably place someone in a group home where they'd live in a dorm style building with other people with similar diagnoses as them. But group homes have closed all over the Seattle area in the past few years because of a lack of government support and because Medicaid pays so little for patients with serious mental illness that these institutions lose money on each patient they take in. It's a sign. Deinstitutionalization isn't just a thing of the past. It's still playing out in some form today. What's left is a dumped out lego bin of supportive housing, enhanced services facilities, adult family homes, the few remaining group homes. Some are run by nonprofits, others by government. Each has its own criteria. Its Own specialties, its own rules about who gets in and who doesn't.

[Esme Jimenez]

When the discharge team is doing that, do they just have like this giant database? Like, what does it look like?

[Will James]

I imagine like you have, like the matrix, like, in front of you, and you could see, like, every bed in the state.

[Aaron Gadue]

Right. It would be amazing if we did. Although I will say at Western State Hospital, it's not a matrix, it's a whiteboard saying, heard about this resource up here in Jefferson county, like, they've got three beds available. Go everyone who you know, let's get on it. It is very much word of mouth. Our social workers are cold calling and sweet talking and trying to do whatever we can to kind of wheel and deal with.

[Will James]

One reason this job requires wheeling and dealing is that every part of this process is voluntary. Aaron's social workers can't force Adam to go somewhere, and they can't force anyone to accept him.

[Esme Jimenez]

So it's like dating. You have to say yes to them and they have to say back yes to you.

[Aaron Gadue]

Exactly, exactly. So we have to work with the patient and say, we have this opportunity at this enhanced service facility. It will require you living there. There's going to be staff on site. There's going to be some level of engagement. You'll have to agree to that. We can't force you to go there. Every provider agency that runs these types of facilities as well may have their own restrictions and their ability to kind of decide whether or not somebody is a good fit for their facility. And so it becomes a lot of kind of negotiation with facilities. A lot of our patients are used to having to do interviews, sit down, and actually get grilled by providers of, like, here are the rules that you have to follow in order to live here. It can be challenging.

[Will James]

Esme learned that at one point, social workers offered to place Adam in a halfway house, but he turned that down.

[Esme Jimenez]

What I've heard from his sister Bethany is that she thinks Adam just didn't want his freedom to be cut off. He was kind of under the impression if I say yes to any of these services right, they won't let me go, and I'd rather just have the freedom to go. So that's what Bethany thinks was happening in his. In her brother's mind.

[Will James]

Aaron says it's normal for patients to have strong ideas about where they want to go after the hospital.

[Aaron Gadue]

I'll give an example. We have a patient currently that only wants to live on a farm on the moon, and that is where he wants to live. And it Becomes a conversation of some good old fashioned kind of clinical work and motivational interviewing. And maybe we're going to go take you out to some less urban areas that might feel similar to a farm on the moon. That's okay. We can commit to doing that and kind of working with the patient. A lot of our patients are pretty anxious to get out of the hospital, though. Some patients are like, I don't care where you send me, sign me up, let's do it. And so we have to juggle that as well.

[Will James]

I hear that the patient's own needs are one factor. You have to juggle the requirements of the service provider, the housing provider, whatever, is another thing you have to take into account. Does scarce, just pure scarcity ever factor in?

[Aaron Gadue]

Absolutely. I mean, independent housing, the lack of affordable housing is an area of scarcity that we constantly butt up against. It can take a year of applying for an apartment before you actually get accepted. And we have had patients that have been committed working with a housing provider while they're at the state hospital, and it takes has taken a year to actually get accepted. Part of that is affordability, Part of that is background checks. And the reality is you're putting Western state hospital as your current address. And with that comes stigma and challenges. We've also had patients that we've literally done statewide searches for. They may need a specific type of service. They may prefer to live in a specific type of setting. We have quite literally exhausted all of our statewide options. That has happened. And then we start over again and we start knocking on doors and we say, all right, well, you didn't want to accept them six months ago, and here, here's all the progress they've made. Let's start again.

[Will James]

But Adam was not waiting a year or six months for social workers to figure out his next step. Adam wanted to leave, and the state decided it couldn't hold him there. Involuntarily, social workers asked Heidi if she could take in Adam at her house in Portland, Oregon. Adam hadn't lived with his mom for about a decade.

[Esme Jimenez]

Heidi starts reflecting and thinking, can I really take care of my son? You know, what's it going to look like if he starts using drugs again? She didn't feel equipped to actually handle that.

[Will James]

As Heidi tells it, she didn't write off the possibility of taking in Adam at her house. She just wanted some kind of professional support. When Adam lived with Heidi years earlier, at one point, he attacked her couch with an axe, and his brother took him in.

[Heidi Urand]

I do not know anything about mental Illness. I do not know how to deal with it. And my meaning maybe was not clear, but my meaning was, I need help with that. I can't do that on my own.

[Bethany Anderson]

It's not that nobody wanted to be there. I think my mom and I were both at this point where we were pleading for help because we didn't know how to help my brother. I mean, I've got a toddler. I can't risk a relapse.

[Will James]

Then, as Adam's discharge date approached, Heidi and Bethany learned doctors were weaning him off his medication. Esme wasn't able to confirm this. The state says any information about Adam's medication is private.

[Aaron Gadue]

Not every patient needs to be on psychiatric medications on a daily basis.

[Will James]

Again, Aaron says he can't talk about Adam's case specifically, but says this would not necessarily be unusual.

[Aaron Gadue]

Ideally, we don't have to put patients on a bunch of meds every day and have them be on meds for the rest of their life. And so there are situations where psychiatrists will work on adjusting, tailoring meds specific to the client's needs. That's basing it on symptoms that they're experiencing, side effects. And so there are patients that will be weaned off of medications that's in coordination with the patient, Very close coordination.

[Will James]

Heidi and Bethany say it was a matter of weeks before they noticed Adam backsliding.

[Bethany Anderson]

Between the beginning of January and middle of January, you see this change. And then the voice got darker, and the little whispers started again. And the smart comments, the really crude behavior, you could hear it in him.

[Heidi Urand]

And the aggravation.

[Bethany Anderson]

The aggravation.

[Heidi Urand]

The aggravation. Aggravate. Yeah, he was just angry.

[Will James]

Heidi was still talking on the phone with Adam every day, and she says the conversations turned to a familiar topic. The light inside of him that could heal people and could protect him, even if he had nowhere to go. Once he left the hospital, right before.

[Heidi Urand]

He left, he started talking to himself. I could hear it. And then he said the light would take care of him. You know, so, no, he wasn't okay.

[Esme Jimenez]

Heidi in phone calls, noticed that Adam was trying to talk about the light. When she said, for example, how are you gonna stay warm, right? You're gonna be discharged in February in Seattle, and it's gonna be cold in the winter. He was like, the light will keep me warm. And so that kind of threw up a flare for her and was like, is my son okay? Should he be being discharged right now? And so she emails the social worker saying, adam's talking about the light again, I'm curious if anyone's watching him.

[Will James]

Aaron says social workers take families input into account when they're discharging a patient. But family's wishes don't always line up with the laws the hospital has to follow.

[Aaron Gadue]

Just having delusions doesn't mean that you should be committed at a state hospital. And there are some people in the community that will have continued delusions, and that may just be their baseline. But we really do have to look at it from the civil commitment criteria and our ability to stabilize and to treat and to continue to petition and tell the court that this person's a danger to others. It can be challenging, I think, that that alignment of families, hopes and goals and desires for patients and also working with individuals that are adults and can make their own decisions.

[Esme Jimenez]

I remember you had sent emails to the social worker when you learned that he was being discharged, and you had said, you know, hey, Adam's telling me about this light. What was going through your head at that point?

[Heidi Urand]

I was frantic. I didn't know what to do.

[Unnamed Family Member]

I didn't know what to do. I just don't think they realized, you know, or cared. Because in all the notes, I didn't see anything where they talked to a psychiatrist and said, adam's talking to himself again.

[Heidi Urand]

She said, well, we'll see if. If anybody hears him. Well, who's going to hear him when he's walking up and down the halls?

[Unnamed Family Member]

And of course, he's smart enough to.

[Heidi Urand]

Stay away from you.

[Unnamed Family Member]

He's not engaging.

[Heidi Urand]

You may think he's engaging with you, but he's playing the game.

[Unnamed Family Member]

He was smart.

[Will James]

So, like, even though Adam wants to be released, even though the hospital is saying they don't have grounds to keep him anymore, Adam's mom is like, there's a sign that he's not ready to be released.

[Esme Jimenez]

Yes. And the email that Heidi gets back from the hospital is, thanks for letting us know he is going to be discharged next week.

[Will James]

However, Adam was out of options and out of time. Some states have made it illegal to discharge someone from a psychiatric hospital into homelessness. Washington is not one of those states.

[Esme Jimenez]

How often do people get discharged to homeless shelters?

[Aaron Gadue]

Not often. It's always our last resort.

[Will James]

Aaron Gadue, who oversees patient discharge for the state, says this happens when a patient's needs and wants don't match the available housing options and time runs out.

[Aaron Gadue]

We're looking at balancing client rights. And it is not illegal to say, I want to go live in a homeless shelter. That may not be my preference. But that might be someone's preference is maybe that's because of what they know. Finding independent housing takes a while. That alignment doesn't always jive with patients saying, get me the heck out of here. I want to go, you know, send me to Bread Alive Mission. I've stayed there before. I know I can get a hot meal there. If that's what they know and they feel comfortable, we have to listen to that. And so it becomes a really difficult decision. We take it very seriously.

[Will James]

Heidi decided if Adam was going to be homeless again, she was going to try to prepare him.

[Heidi Urand]

He wanted to do certain things. So I looked up the streets of where he wanted to go and what he wanted to do and where the help was, you know, the Social Security office, all of that. And I had it all written out, where it was, what the address was, where, you know, everything was. So he wasn't shooting in the dark if he was going to really do this.

[Bethany Anderson]

My mom was really on top of it. She was calling, emailing, leaving voicemails for the social worker constantly. She was, hey, can we do this? Can we do this? This is where, as a family, we're trying our best.

[Will James]

Heidi and Bethany say they were surprised social workers at Western State did not sign Adam up for Social Security disability payments in advance. It seemed like such a straightforward way to help Adam land on his feet. He had a lifelong disability due to his brittle bone disease. Why leave him to navigate that process on his own? Adam Aaron says his social workers at state hospitals actually are not allowed to set patients up with Social Security disability payments. Patients aren't eligible for these benefits while they're under the state's care.

[Aaron Gadue]

That's one of our big gaps that we face in the state, and many states face this gap. When you are in an institution, whether that's jail or prison or a state hospital or a community psychiatric facility for more than 90 days, give or take. Medicaid is actually inactivated. For most patients, access to Social Security is either put on pause or it's actually terminated as well. And patients can't access those benefits until they are actually out of the institution and can prove to the Social Security administration that they're no longer in an institution.

[Will James]

These are not mistakes. These are government rules that have built gaps into the discharge process. And when a patient leaves one institution, these gaps allow space for them to get lost in before getting help somewhere else. These gaps open up when social workers try to set up a patient with addiction treatment or follow up mental health care before they leave the state. Psychiatric Hospital. Those providers can't bill Medicaid for going to Western State to evaluate a patient who's getting ready for discharge, so they often don't go at all. These gaps even appear when social workers try to set up a patient with a spot in a homeless shelter.

[Aaron Gadue]

Inpatient psychiatric care does not align with our homeless services system. We're getting in line just like everybody else. We're oftentimes having to not have any guarantee that there's a shelter bed. And to give you an example, we multiple times have had to backdoor the systems a little bit and actually discharge a patient from the state hospital to a short term motel run by a homeless service provider for one night so that they are homeless for one night, technically, so that they can then access homeless specific services. There's very limited coordination when it comes to the homeless service world and the inpatient psychiatric world.

[Will James]

Adam was released on February 7, 2023. Heidi says she was told Adam was put in a taxi and dropped off in downtown Seattle. Records show he was released with his ID, $40 in cash, 30 days of medicine, plus a prescription. But the records don't say what it was for. And a 1-800-number for the county's crisis hotline, Western State had fulfilled its role in Adam's story. As we saw in the records, Adam was officially handed off to a homeless shelter, the Bread of Life Mission. It's a little brick storefront in an old neighborhood called Pioneer Square. Outside, there's a faded sign with a picture of Jesus either knocking on a door or opening it. When Esme checked with shelter staff later, they had no record of Adam staying the night there. It's not clear he ever stepped inside.

[Aaron Gadue]

He's not in our system, so he didn't stay here overnight. A lot of times the hospital would release certain people and say, go to.

[Derek Derricks]

The Bread of Life Mission, but that.

[Aaron Gadue]

Don'T mean that they will come here and stay.

[Will James]

Staff told Esme. Psychiatric hospitals send patients to the shelter three or four times a month, but they often don't show up. Heidi had helped Adam make a plan after he got released. He was going to head over to a Social Security office half a mile away and sign up for disability benefits so he'd have an income. Western States staff had sent Adam off with discharge paperwork that would help him prove he was eligible. But right away, that plan fell apart.

[Heidi Urand]

So I heard from him the day he was discharged. He was having a hard time. He was at Social Security, but he had lost his bag, which had his release papers. I guess somebody Stole his bag. He was borrowing somebody's phone, and we were setting him up with a plan.

[Will James]

They decided Adam would buy a phone so they could stay in touch. Heidi waited but didn't get another call from him. Within hours of Adam's discharge from western state, Heidi could see the churn pulling him back in. She might have one shot to pull him out before it took hold. She started calling homeless shelters, trying to find him.

[Heidi Urand]

None of the missions would let you know whether they saw him. So I started watching the street camps to see if I saw him.

[Esme Jimenez]

Heidi told me that she found Adam through street cameras. And I remember I was like, what do you mean? And she's like, the camera's in Seattle. And sure enough, there are these cameras all over downtown Seattle pointing at some of these key intersections.

[Will James]

These cameras monitor traffic for the Seattle department of transportation. Heidi says she heard about cameras like these on a science fiction TV show called fringe. She figured out how to tune into their livestreams. And as days ticked by after Adam's discharge, Heidi watched these live streams and searched for him.

[Heidi Urand]

I had made him a list of community things. The library where he could use the computer for free. You know, this is here, this is here. And so that's where I started looking at all the cameras. And at one point, I had, like, three items on with cameras looking and.

[Will James]

Three different, like, devices.

[Heidi Urand]

Yeah, cameras up. Yeah.

[Will James]

In the heart of Seattle's churn, in the middle of a concentration of homeless shelters, hospital bill courthouses, and the jail, there's a fountain. It's fenced off now, but for years, you could walk past this fountain and reliably see people hanging out, selling drugs, using drugs, Some of them in some kind of crisis. Heidi, from her home in Portland, a three hour drive away, watched this fountain through a traffic camera.

[Heidi Urand]

I saw him Saturday morning. I think it was Saturday. I saw Adam.

[Esme Jimenez]

And she said that she found her son because of the specific gait of his walk. He has brittle bone disease, so he walks in a slightly different pattern.

[Heidi Urand]

He was distinct in the way his sit and his walk was because of all the breaks and everything else and his bad back.

[Esme Jimenez]

To me, that speaks to, like, a mother's devotion and desperation that she's watching these cameras. I don't know how long she took to actually find him. You know, I remember Bethany was his sister, was like, my mom was like a stalker staring at these cameras, trying to find Adam. And she did. She found Adam and then drove up to Seattle to find him.

[Heidi Urand]

So I took off. I went around to where the fountain was. And he wasn't there. And so I came around this way to the park, and he's over here on the sidewalk. And I said, adam, get in the car. And I don't know if he recognized me or not, but he got in the car. I said, do you want a hamburger? Let's go get a hamburger.

[Esme Jimenez]

She wants to make sure he's eating. She wants to make sure he's not using drugs while they're hanging out.

[Heidi Urand]

I tried to talk to him. He was talking to himself. I said, did you do drugs today? And he says, well, I smoked something out of a pipe. And I'm like, okay. And so we talked, and I said, do you want to come home? And, no, I don't want to go to your house. And I was like, okay. So I figured I'd waste time with him and he'd stop being high, because I figured he was high.

[Will James]

Heidi got a hotel room for both of them that night. She was trying to buy time to let Adam sober up and to come up with a plan. Maybe she could convince Adam to come home with her. Now that she saw how badly his discharge was going, that didn't seem like such a bad idea anymore.

[Heidi Urand]

I turned the TV on. I told him, we can go get you some clothes and you can take a shower. And he went in, and I think he acted like he had a shower. I think he turned on the water and talked to himself for a good two hours in there. But maybe he took a shower. May I talk to him? And, you know, he talked to himself quite a bit.

[Derek Derricks]

I'm sorry. Not run into you.

[Will James]

They don't want to run into you. This is when Heidi decided to make a video of Adam. The recording we heard back at the beginning of this series. She wanted a record of how he was doing just days after leaving Western State.

[Unnamed Family Member]

Who are you talking to?

[Derek Derricks]

Well, is it all right?

[Heidi Urand]

Yeah.

[Will James]

Can I just be here for a minute?

[Derek Derricks]

And public.

[Will James]

I can't remember.

[Heidi Urand]

I don't to this day know if it was drugs or if it was the schizophrenia. I know Bethany was freaked out because I stayed there with him, but if it was drugs, I was trying to wait him out as long as I could.

[Will James]

Heidi says she stayed up watching the news. Some of the stories were about the mental health crisis on Seattle's streets. Adam stayed up drinking sodas, not really talking with her. Heidi slept for a couple hours and thinks Adam might have slept a couple hours, too.

[Heidi Urand]

Then in the morning, I started again. Do you want to go to the house, get cleaned up? Maybe see if we can't get you some medicine. And nope, I don't want to. I want to live my life my way. So I took him to breakfast, and then I took him to the store. And I said, why don't you get some snacks and, you know, some cigarettes and some drinks and.

[Unnamed Family Member]

Offer to give him close kids, but he wouldn't come with me.

[Will James]

Heidi got Adam in her car and started driving around, still trying to stall him. She called a crisis hotline, and the person on the phone told her to take Adam to a hospital.

[Heidi Urand]

I took him to Swedish because that's what the emergency people said to do. And he says, where are we going? I said, well, let's go to Swedish and then we can get your paperwork. He says, if you don't turn the car around, I'm getting out. I said, adam, we can get your paperwork. And he started getting out of the moving car. And so I said, fine, we won't go.

[Esme Jimenez]

And so at that point, she was like, well, what can I possibly keep doing here? I don't want him to hurt himself while I'm trying to get into the hospital. So she gave up on that.

[Unnamed Family Member]

So I parked and I let him go. And I called the crisis line and told him he wouldn't go. And they said they couldn't do anything to call the police. So I called the police.

[Esme Jimenez]

They said they would check up on Adam. And she didn't hear back from police until she left Seattle and drove all the way back to Portland.

[Heidi Urand]

By the time I got here, they.

[Unnamed Family Member]

Had just sent somebody to the park. Just sent somebody. It's a three hour drive. And they didn't find him. And I don't know what I could have done because if I would have took him down the highway and he tried to jump out, he would have died. I don't know. I don't know what I could have done. I called the two entities that are supposed to help you and the crisis. I can't do anything. I don't know what the answer is, but I know that wasn't the answer. You can't just drop somebody off when they have so many issues. You can't give up medication and then stop it and then there's a problem and then just say, well, we're done now. This was fun.

[Will James]

Oh, Derek.

[Unnamed Family Member]

Hey.

[Will James]

Derek Derricks moved to Seattle last year from a rural town in Washington. He started a new job in finance and moved into an apartment a few blocks from Seattle's Space Needle. Esme and I met him a short walk from where he lives.

[Derek Derricks]

This was, like, three days into me moving here. I went to the little convenience store right down there at 7:11. And on my way back is when I saw him. So the bus stop right there. I saw him, like, laying on the ground. I've seen a lot of people in Seattle, a lot of homeless people. And at first I was like, okay, he might be asleep. I don't want to bother him. But it was in the middle of the sidewalk. And I was like, okay, that's a little weird. It was the wintertime, granted. So, like, he could have just been cold. And maybe that's why his face looked like how it did, but he was, like, purple. His leg. Leg was twisted in a strange, like, contorted way. One leg was straight, the other one was twisted, and he was just kind of, like, laying there flat on the ground. You know, it's one of those images that's, like, kind of burned into your brain. And then the guy comes up. He was just another guy on the street. There's another dude walking, and he, like, sprung into action immediately. And he starts giving him chest compression, and he puts Narcan up his nose. Because he's like. This guy is, like, not breathing. He's not breathing. He's not responding. So I just called the cops. They came. It probably took them like, 10, 15 minutes to get here. And they tried for a little bit, but they didn't try for very long. And I saw them pretty much wrap it up, like, wrap them up and put them in the paramedics truck.

[Bethany Anderson]

My mom wasn't going to tell me my brother died. She waited all day. She didn't tell me all day. Normally, she doesn't care when my husband's home, but I had video called her, and she asked me if my husband was home. No, you don't care. What do you? Why Call me back when he gets home. And I didn't think anything of it. I didn't think anything of it until I went to call her back when my husband walked in the door. And I remember I hit call, and it hit me. And I mean, it just. It smacked me in the face. I just knew already what she's gonna say. I was so angry at my brother, but at the same time, I was glad he wasn't in pain anymore.

[Will James]

Adam had overdosed on fentanyl less than a month after Western State discharged him onto the streets of Seattle.

[Esme Jimenez]

Originally, when Adam was brought in, he was a John Doe. No one had identification for him. Eventually, though, they figured out who it was and so they got in contact with his mom, and Bethany and Heidi decided to go up together. And it was a couple days. And because he was pronounced brain dead, they actually had to make the decision to no longer provide care for him. And once they did that, then Adam died. His mom and sister tried to donate his organs, but his organs are so damaged from living on the streets, drug use, probably hunger, they're not able to actually donate those organs. And instead they give Heidi a lock of his hair and a handprint.

[Will James]

It was only after Adam died that Heidi and Esme got records of his treatment from different hospitals, jails, and prison. And Heidi started filling in the eight or so years her son spent churning through these institutions.

[Esme Jimenez]

I remember when you first showed me the documents that you had, and it was 200 plus pages of three different hospitals. @ least I can tell that you cared a lot. And you were like this researcher just trying to go through everything to make sense of what had happened. Is that what was happening for you?

[Unnamed Family Member]

I had to know everything. You've got to know everything. Everything you went through. And just reading those, I could tell that he definitely was schizophrenic. I mean, there are things in there that were just. How could you let a human being go through that? And I'm sorry, but those people I western might as well put a bullet in his head when he walked out that door, because they killed him. They killed him because I told him he was talking to himself, and now he's going, no matter what. Yeah, I know you need that bed space that's more important than somebody's life, because the next one you're not gonna fix has to get in that bed, right?

[Esme Jimenez]

Yeah.

[Unnamed Family Member]

And I'm not. I'm not saying they didn't do good. It's just, what's the point if the end result is just what you were trying to fix to begin with? Open those hospitals and make a difference.

[Heidi Urand]

In people's lives instead of running them through a mill.

[Will James]

When you look back at Adam's story and everything that went wrong, how much of it is the individual aspects of Adam's story and how much of it is universal problems?

[Esme Jimenez]

Yeah, I'm trying to do the math. In my head, my instinct is to go 60, 40. 60 being these universal big issues, and 40 being specific to Adam. So Adam is special. And because he's special, that means it's really hard to find him the right place, the right time, the right needs, and that he'll be in a mindset where he can accept that help. But the Reality is, Adam's not unique. At the end of the day, there are hundreds of people in Washington state and Seattle that have severe mental illness and substance use and potentially other healthcare issues. So Seattle and Washington state, if they want to support the people that are most vulnerable, then have to design and build a different system. Adam's story tells us that for the people that are the sickest, the most vulnerable, and the most in need of help, they are the ones that are going to be the hardest to help. It looks like a collaborative, prolonged effort to bring together housing, mental health support, and substance use support together in order to actually stabilize that person probably for the rest of their life. Not a crisis center that catches them once, not a intervention program once, but something that's steady and is going to catch them every time that they stumble.

[Will James]

This entire series, we've avoided saying a particular combination of words that comes up so often when talking about modern psychiatric care. It's become a cliche. That combination of words is broken system. What Esme says next about Adam is the reason we don't use those words.

[Esme Jimenez]

Technically, everything worked, right? He went to ERS, the ERS took care of him for the 24 hours that they were going to, made sure he didn't hurt himself or others, stabilized him, sent him on his way, right? The jails did what they were supposed to do. He was charged with crimes, right? They held him. When the court system said, well, it was a misdemeanor, it's not high enough. And Western State has backed up, dismiss the charges, they let him go. When I talked to the social workers, when I talked to the er, when I talked to the police, when I talked to Western, they all think that they did the right thing. And legally they did. Technically, everything worked exactly as it should. They followed the letter of the law. They said, here's the way that we're going to interact with this person. And they provided that limited, specific care. The issue was that there was nothing else beyond that. So when you're looking at actually stabilizing a person like Adam with severe mental illness, substance use, and medical needs, that's a lifelong commitment to his health care, his housing, his ability to live like a full human being, just like everyone else, and there's nothing that does that. There's nothing that does that in our current setup.

[Will James]

When we think about this as a broken system, we're looking for flaws for bad guys. But this way of looking at the world has a huge assumption at the center of assumes the machine generally works, the system is basically stable and all that's needed to fix it is some tweaks at the edges. It assumes that if we just point out the dysfunction in the system, if it gets enough attention, maybe a law gets changed, maybe someone gets fired and the machine works again. But like Esme says, what if everything works as intended and this is the result? What if this design comes from decisions made again and again over decades by lots of people choosing how much they want to spend on care, how much responsibility they're prepared to take? What would that say about what we're willing to accept as normal?

[Heidi Urand]

This is not a one person failure. We all failed Adam, somehow or another.

[Will James]

And if that's true, what would it mean to accept something different? Coming up on the final episode of Lost Patients, what recovery looks like for people with serious mental illness, and what recovery might look like for the fragmented world of psychiatric care itself. We'll be back with that episode in two weeks. See you then. Lost Patients is a production of KUOW Public Radio and the Seattle Times in partnership with the NPR Network. You can support Lost Patience by investing in the local newsrooms and the specialized beats that make this sort of storytelling possible. Please consider joining and [e-mail] and seattletimes.com this episode was reported, written and produced by Esme Jimenez, Sydney Brownstone and me, Will James. Our editor is Liz Jones. Additional editing by Diana Samuels, Jonathan Martin, Brendan Sweeney and Marshall Eisen project development by Laura Grenius. Our music is by BC Campbell, mixing and sound design by Hans Twight, logo and branding by Alicia Villa and Michaela Giannatti Boyle. And thank you to Heidi Urant, Bethany Anderson and Erin Gadou for sharing your stories and expert.