The Churn

Summary

Reveal Podcast Episode Summary: "The Churn"

Release Date: April 5, 2025
Host: Al Letson
Produced by: The Center for Investigative Reporting and PRX

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Introduction

In the gripping episode titled "The Churn," Reveal delves deep into the systemic failures of mental health care in Washington state through the tragic story of Adam Urand. Host Al Letson, alongside award-winning reporters Will James and Esme Jimenez, unpacks how individuals with severe mental illness can become entrapped in a perpetual cycle of inadequate treatment, homelessness, and ultimately, loss of life.

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Adam Urand's Struggle

Early Signs and Diagnosis

From a young age, Adam Urand exhibited a knack for fixing things, a trait highlighted by his mother, Heidi Urand. "As a kid, like 6, 7 years old, he'd go get lawn mowers that adults had given up on, put them back together, and they'd run." (00:35)

Despite his early abilities, Adam began showing signs of severe mental illness. He was diagnosed with schizophrenia, bipolar disorder, and schizoaffective disorder. Coupled with substance abuse—heroin and methamphetamine—the lines between cause and effect blurred, complicating his path to stability.

Cycle of the Churn

Adam's adult life was marked by repeated entries into jails, emergency rooms, and psychiatric hospitals. This relentless cycle is often referred to as "the churn," where individuals with serious mental illnesses receive fragmented care without comprehensive, lasting support. As Will James narrates, "Adam spent about eight years of his life, almost all of his 30s, cycling in and out of jails, emergency rooms, short hospital stays, and a stint in prison." (01:05)

Involuntary Commitment and Discharge

In 2022, Adam was involuntarily committed to Western State, Washington's largest psychiatric hospital. His family hoped this would be the turning point. Initially, medication appeared effective. "When he was on the medication at the mental hospital, I talked to Adam every day. Sometimes I talked to him twice." – Heidi Urand (03:41)

However, after nine months, the hospital decided not to renew his commitment, citing that Adam was "completely asymptomatic." Without adequate support, social workers could only offer placements in facilities, which Adam declined, leading to his discharge into a homeless shelter—a last resort seldom utilized. "We can't force you to live there," explained Lou Middleton, reflecting the limitations faced by social workers in securing stable housing for Adam. (06:41)

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Systemic Failures in Mental Health Care

Lack of Comprehensive Support

Adam's discharge uncovered a significant gap in the mental health care system. While state institutions followed legal protocols, they lacked the infrastructure to provide continuous, community-based support essential for individuals like Adam. "They followed the letter of the law. The issue was that there was nothing else beyond that." – Aaron Gadou (20:28)

Impact of Deinstitutionalization

The episode traces the roots of these systemic issues back to the 1960s, during President Kennedy's push for deinstitutionalization. Although the intent was to integrate mentally ill individuals into communities, the execution faltered due to inadequate funding and infrastructure. Sidney Brownstone, an investigative journalist, highlights, "State psychiatric hospitals had been shrinking and closing for two decades. Meanwhile, the rollout of community care was slow, and eventually those efforts stalled because of funding problems." (26:37)

Consequences Today

The historical lack of sustained community support has resulted in many individuals cycling through institutions without ever achieving stability. Adam's story is a poignant example of how these systemic shortcomings culminate in personal tragedy. Heidi Urand expresses her heartbreak, "This is not a one person failure. We all failed Adam somehow or another." (18:34)

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A Glimmer of Hope: Lou Middleton's Recovery

Early Struggles with Mental Illness

Parallel to Adam's story is that of Lou Middleton (referred to as Derek in the transcript), who battled severe mental illness characterized by auditory hallucinations. His early experiences were marked by paranoia and delusions, significantly impacting his daily life. "The voices were criticizing Lou's taste in music... 'Hi, this is Annie Lennox...'" (40:42)

Path to Recovery

Despite the challenges, Lou found a path to recovery through a combination of hospitalization, medication, and supportive housing. Critical to his turnaround was an ex-girlfriend's intervention, leading to his commitment to Harborview Medical Center. "She convinced Lou to get the bite wound checked out, and then she convinced him to stay for a psychiatric evaluation." (42:22)

Building a Supportive Community

Lou's journey culminated in his employment with the downtown emergency service center, where he became a certified peer counselor. This role allowed him to support others grappling with similar struggles, emphasizing the importance of community and mutual support in managing mental illness. "Lou led his support groups in a back room of this center... gradually getting people to see these voices not as outside entities, but as parts of themselves." (51:31)

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Conclusion and Reflections

"The Churn" underscores the intricate web of systemic failures that trap individuals like Adam Urand in a relentless cycle of inadequate mental health care and homelessness. Through historical context and personal narratives, Reveal highlights the urgent need for comprehensive, community-based support systems to prevent such tragedies.

Adam's story serves as a stark reminder of what happens when the mental health safety net is incomplete. In contrast, Lou Middleton's recovery offers a beacon of hope, illustrating that with the right support and resources, individuals can navigate their mental illnesses towards meaningful recovery.

Notable Quotes:

• "I was excited that maybe somebody was going to get to the bottom of the mental illness and help him, but..." – Heidi Urand (02:55)
• "Technically, everything worked, right? They went to ERs, jails did what they were supposed to do... The issue was that there was nothing else beyond that." – Aaron Gadou (20:28)
• "This is not a one person failure. We all failed Adam somehow or another." – Heidi Urand (18:34)
• "Lou had what he calls window periods when he'd have more clarity." – Esme Jimenez (44:26)
• "Recovery does not mean the symptoms are gone... we have to realize they're imperfect." – Lou Middleton (51:49)

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Further Listening

For a deeper exploration of Adam Urand's story, the historical context of mental health care in the United States, and inspiring narratives of recovery, listen to the full episode of "The Churn" on Reveal.

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Learn more about Reveal at revealnews.org/learn.

Transcript

[Al Letson]

This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool from Progressive, you can find options that fit your budget and potentially lower your bills. Try [e-mail], progressive Casualty Insurance Company and affiliates. Price and coverage match limited by state law. Not available in all states.

[Will James]

From the center for Investigative Reporting and prx, this is Reveal. I'm Al Edson. For as long as his family can remember, Adam Urand wanted to fix things.

[Heidi Urand]

As a kid, like 6, 7 years old, he'd go get lawn mowers that adults had given up on, put them back together, and they'd run.

[Will James]

Heidi Urand is Adam's mom. She has a photo of Adam from when he was even younger, around 3 years old. He's underneath his red, yellow and blue tricycle, a big Wheel pretending to be a mechanic working under a car.

[Heidi Urand]

That is Adam. He was working on his big Wheel.

[Esme Jimenez]

Yeah.

[Heidi Urand]

Who was gonna fix it?

[Will James]

Adam grew up to be an actual mechanic, giving new life to banged up cars up and down the Pacific Northwest. One night around 2013, Adam calls his sister Bethany in the middle of the.

[Bethany Anderson]

Night, it was probably midnight, one o' clock in the morning. And my oldest brother, he gets a call and I get a call both from Adam telling us that there's somebody there outside of the shop.

[Will James]

It wasn't what Bethany and her other brother expected.

[Bethany Anderson]

And I remember Jason and I, we both pulled up and we were like, what's going on? There was no one there.

[Will James]

Adam was showing signs of paranoia. At one point, he attacked a couch in his mother's house with an ax. And later, Adam talked about this light inside of him that he, he believed could protect and heal those around him. Doctors would eventually diagnose Adam with schizophrenia, bipolar disorder, and schizoaffective disorder. Adam's family isn't sure when it started, but at some point, Adam also started using heroin and meth. And it became increasingly difficult to untangle which had become the cause and which was the effect. Adam spent about eight years of his life, almost all of his 30s, cycling in and out of jails, emergency rooms, short hospital stays, and a stint in prison. Adam would ultimately end up living on the streets, becoming caught in what is often referred to as the churn, when someone with serious mental illness goes in and out of different treatment systems, often for years, without getting the lasting help they need. In 2022, state authorities committed Adam, against his will, to Washington's largest psychiatric hospital, Western State. Adam's family hoped he would get the help he needed.

[Heidi Urand]

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

[Will James]

Unfortunately, that's not what happened. Today we're revisiting an episode we made in partnership with a podcast from KUOW and the Seattle Times called It takes a deeply reported look at failures in mental health care through stories based in Washington state. Reporter Will James picks up the story with what happens to Adam after he gets committed to the state hospital.

[Esme Jimenez]

There's not a lot of publicly available information about Adam's time at Western State, but we know from his family that he was put on medication and it seemed to be working.

[Heidi Urand]

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

[Esme Jimenez]

That's Adam's mom, Heidi. Again, these cogent conversations were a huge change compared to how Adam was before his hospitalization. Adam's sister, Bethany Anderson, agrees.

[Bethany Anderson]

Once the fog lifted, 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.

[Esme Jimenez]

But Adam's mom, Heidi, also noticed some things that worried her. Adam seemed to avoid talking to staff in the hospital and spent a lot of time walking the hallways alone. It went like this until about nine months into Adam's stay, when his family learned he was going to be discharged. My reporting partner, Esme Jimenez, spent months digging into Adam's case and asked the.

[Aaron Gadou]

State why they released him 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.

[Esme Jimenez]

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 Adams commitment again. Aaron Gadou 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.

[Lou Middleton]

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

[Esme Jimenez]

Aaron said he couldn't talk about Adam specifically because of patient privacy rules, but he could speak to the process generally.

[Lou Middleton]

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.

[Esme Jimenez]

The team of social workers that Aaron leads help line up homes and follow up care for patients like Adam as they get ready to leave the hospital. But they can't force Adam to go anywhere. All they can do is offer placements in facilities that could be helpful.

[Lou Middleton]

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.

[Esme Jimenez]

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.

[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.

[Esme Jimenez]

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. Just before Adam was discharged from western state, his mom noticed something was wrong.

[Heidi Urand]

Right before 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.

[Aaron Gadou]

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. 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.

[Esme Jimenez]

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.

[Lou Middleton]

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.

[Esme Jimenez]

Ultimately, social workers offered to send Adam to a halfway house, and he turned that down. So they discharged him to a homeless shelter.

[Aaron Gadou]

How often do people get discharged to homeless shelters?

[Lou Middleton]

Not often. It's always our last resort.

[Esme Jimenez]

Some states have made it illegal to discharge someone from a psychiatric hospital into homelessness. Washington is not one of those states. Heidi decided if Adam was going to be homeless again, she was going to try to prepare him.

[Heidi Urand]

So I looked up the streets of where he wanted to go and where the help was, all of that, and I had it all written out 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.

[Esme Jimenez]

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. Esme saw in the records Adam was officially handed off to a homeless shelter, the Bread of Life Mission. 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.

[Derek]

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 the Bread of Life Mission, but that don't mean that they will come here and stay.

[Esme Jimenez]

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. 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.

[Esme Jimenez]

They decided Adam would buy a phone so they could stay in touch. Heidi waited but didn't get another call from him. 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.

[Aaron Gadou]

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

[Esme Jimenez]

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.

[Aaron Gadou]

Their livestreams, and she said that she found her son because of the specific gait of his walk.

[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 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.

[Esme Jimenez]

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 I talked to him, and, you know, he talked to himself quite a bit.

[Derek]

I'm sorry I've run into you.

[Esme Jimenez]

They don't want to run into you. This is when Heidi decided to make a video of Adam. She wanted a record of how he was doing just days after leaving Western State.

[Heidi Urand]

Who you talking to?

[Derek]

Well, is it all right?

[Heidi Urand]

Yeah.

[Esme Jimenez]

Can I just be here for a.

[Derek]

Minute and talk, everybody?

[Heidi Urand]

I don't to this day know if it was drugs or if it was the schizophrenia, if it was drugs. I was trying to wait him out as long as I could.

[Esme Jimenez]

Heidi says she stayed up watching the news. Some of the stories were about the mental health crisis on Seattle 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 start it 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.

[Esme Jimenez]

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.

[Aaron Gadou]

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.

[Heidi Urand]

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.

[Aaron Gadou]

They said they would check up on Adam. 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 had just sent somebody to the park. Just sent somebody. It's a three hour drive.

[Dan Evans]

And they didn't find him.

[Heidi Urand]

I don't know what the answer is, but I know that wasn't the answer.

[Esme Jimenez]

Oh, Derek. Hey. Derek. Derricks moved to Seattle 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.

[Will James]

So the bus stop right there, I.

[Esme Jimenez]

Saw him, like, laying on the ground. And then there's another dude walking, and.

[Will James]

He, like, sprung into action even 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.

[Esme Jimenez]

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.

[Will James]

It up, like wrap them up and.

[Esme Jimenez]

Put him in the paramedic 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. And she asked me if my husband was home. No, you don't care. What do you.

[Heidi Urand]

Why?

[Bethany Anderson]

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. I was so angry at my brother, but at the same time, I was glad he wasn't in pain anymore.

[Esme Jimenez]

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

[Heidi Urand]

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

[Esme Jimenez]

Esme, my reporting partner, collected hundreds of pages of records from the years Adam spent cycling through emergency rooms, psychiatric hospitals, jails, and prison. I talked with Esme about why this pattern kept repeating. 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?

[Aaron Gadou]

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 them go. When I talk to the social workers, when I talk to the er, when I talk to the police, when I talk 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 come back, the team from Lost patients goes back in time.

[Esme Jimenez]

If we launch a broad new mental health program now, it will be possible within a decade or two to reduce the number of patients now under custodial.

[Will James]

Care in the hopes of understanding why the safety net that was designed to catch people like Adam has fallen apart over the years. That's coming up next on Reveal.

[Bethany Anderson]

If you're listening to this show, you care about stories that investigate the truth and impact millions. I'm Danielle Elliott and on Climbing the Walls, I'm digging into the rise of ADHD diagnoses among women. I'm exploring what happens now that the world is finally starting to catch up with what women have been saying for decades. I don't know what happened, but the.

[Esme Jimenez]

Algorithm heard the conversation and figured out.

[Bethany Anderson]

You'Re a black woman with adhd.

[Esme Jimenez]

We still get misdiagnosed with depression or.

[Heidi Urand]

They see depression, but they don't see the ADHD component to it or the comorbidity.

[Bethany Anderson]

Join me as we explore why women have been left out of the ADHD conversation for so long. We're talking to mental health experts, sharing real stories and uncovering the truths that you need to hear to listen to Climbing the Walls Search for Climbing the Walls in your favorite podcast app.

[Will James]

This is an especially terrible time to be a refugee because after fleeing war, violence and persecution, it seems like the world's capacity for compassion is running short. And as the numbers of refugees globally reach catastrophic levels, UNHCR, the UN Refugee Agency, needs your support. In just 72 hours, your donation will deliver shelter, protection and food to refugees when they need it most. Your compassion today will make a life saving difference. Go to unrefugees.org donation to make your gift.

[Esme Jimenez]

Hi, this is Marla from the Human Resources team at the center for Investigative Reporting. Subscriptions Paywalls? No, not here. We believe that groundbreaking journalism should be accessible to everyone. If you can pitch in just a.

[Bethany Anderson]

Little, please donate today.

[Esme Jimenez]

Just text the word give to 88857 reveal. That's 888-577-3832 or visit revealnews.org donate no gift is too small. Thank you.

[Will James]

From the center for Investigative Reporting and prx. This is Reveal. I'm Al. We're revisiting our partnership with kuow, the Seattle Times, and the team behind the podcast Lost Patients, a show that investigates the state of mental health care in.

[Esme Jimenez]

The US with respect to mental illness. Our chief aim is to get people out of state custodial institutions and back into their communities and homes without hardship or danger.

[Will James]

Back in the 1960s. During John F. Kennedy's administration, our country's relationship to mental health care was going through a revolution for about a century. At that point, many people with serious mental illness were treated in state run psychiatric hospitals held on sprawling campuses where they were sometimes separated from society for the rest of their lives. Depending on the latest trend in psychiatry, doctors might subject patients to forced sterilizations, induce comas, lobotomies. But President Kennedy had a new vision, shutting down these asylums and transferring patients to smaller treatment centers in their communities. This was based in part on the idea that newly discovered antipsychotic drugs could cure people with conditions like schizophrenia. In 1963, Kennedy signed the Community Mental Health act, setting aside $150 million to build and staff the 1500 Community Mental Health centers around the country.

[Esme Jimenez]

If we launch a broad new mental health program now, it will be possible within a decade or two to reduce the number of patients now under custodial care by 50% or more.

[Will James]

This marked the beginning of a process known as deinstitutionalization. And over the next 50 years, the US would see more than 80% of state psychiatric beds vanish. Reporter Will James takes us back to the 1980s, when it had become painfully clear that deinstitutionalization had gone disastrously off course.

[Esme Jimenez]

From National Public Radio, this is Horizons. This NPR story from 1984 documents a phenomenon people were seeing in cities all around the US at that time. A rise in people who seemed seriously mentally ill and were living on the streets. In this edition of Horizons, Frank Stacio reports that some experts fear the streets have become the asylum of the 80s. After more than two decades, deinstitutionalization has yet to be carried out as it was first planned. While hospitals have emptied their beds, follow up care is erratic and often neglected. By the early 80s, state psychiatric hospitals had been shrinking and closing for two decades. Meanwhile, the rollout of community care was slow, and eventually those efforts stalled because of funding problems. A decade and a half after Kennedy called for 1,500 community mental health centers, only half of those were built. Patients left the hospital for locally operated halfway houses and community mental health centers. But the dollars never followed. The community mental health centers that did exist provided a mishmash of different types of care. While these centers technically treated mental illness, many of them catered to people who were very different from the patients who had been at state psychiatric hospitals, the community mental health centers, with only rare exceptions, have never picked up and taken care of the seriously mentally ill. Psychiatrist E. Fuller Torre spoke with NPR in 1984. Fuller Torre would later become a leading voice calling for more involuntary commitment. Back then, he was reflecting what a lot of mental health workers were seeing. The community mental health centers have been middle class psychiatry for people with problems of living. They have not confronted the problem of people with schizophrenia, manic depressive disorder, and the severe mental illnesses. It was clear by this point that the antipsychotic drugs that had given psychiatrists so much optimism decades earlier, the drugs that set the stage for deinstitutionalization, did not work as well as they had hoped. It turned out these drugs were useful tools for managing psychosis, but not a cure. By the 80s, there had been no major advances in these drugs for three decades. There was something else going on, too, something that's often unappreciated in the story of how deinstitutionalization contributed to people with serious mental illness ending up on the streets. Kennedy's vision was to treat patients, quote, in their communities and homes, community care assumed that seriously mentally ill people could find places to Live. From the 1970s onward, in many cities around the US homes for the poorest people were disappearing. Kim Hopper, an anthropologist who has studied mental illness and homelessness, also talked with NPR in 1984. The difference between the absolutely abject marginal population today and the absolutely abject marginal population of 15 years ago is that 15 years ago they could afford crappy housing, and today there isn't even any of that here in Seattle. The city's center was home to canyons of residential hotels, where for decades, thousands of the city's poorest people could rent a room for a few dollars a week. These were called single room occupancy buildings, or SROs. Many were fire traps, poorly maintained. But SROs were a reliable source of housing someone could afford on government assistance or poverty wages. Just as deinstitutionalization swept the country, these residential hotels got regulated and redeveloped out of existence, sometimes transformed into more upscale apartments.

[Dan Evans]

This is an era of massive change for the most vulnerable people in our society.

[Esme Jimenez]

Sidney Brownstone is an investigative journalist at the Seattle Times who dug into the impact of this time period for our podcast series.

[Dan Evans]

And yet that wasn't really felt by middle class or otherwise comfortable people at all. It went by without a lot of comment, without a ton of political strife. And we carried on as if things were normal until we fast forward 20 or 30 or 40 years and all of those decisions that we made are breaking through the surface.

[Esme Jimenez]

Sidney was searching in the Seattle Times archives for evidence of what happened to the lost Patients of hospitals that closed around here. Hospitals like Northern State, a sprawling psychiatric complex that first opened in the early 1900s and was closed during deinstitutionalization in 1973. In the archives of stories about Northern State, Sydney stumbled on a missing link connecting the era of deinstitutionalization to today.

[Dan Evans]

Oh, wow. The headline of this piece is the mentally Ill victims of an Experiment that Failed. And this is how it begins. Crowds rush past them on downtown streets, pretending not to hear their confused or angry chatter. They are studiously.

[Esme Jimenez]

Sydney noticed this story from 1981 had some of the same language she used in her reporting on homelessness. More than four decades later, even the institutions were the same.

[Dan Evans]

Oh my God. This paragraph was written in 1981. Many mentally ill people find themselves caught in a revolving door that leads them from Harborview Medical center to Western State Hospital to a place like the downtown emergency center in the Morrison Hotel, and then back onto the streets, where the cycle begins again. It froze me. A lot of things were flooding my brain at once, like, holy. The exact same thing is happening now. People are bouncing from the Morrison to the downtown King County Jail to Western and back again. We've been stuck in the same calcified loop for 40 years. And it's like we have made a decision as a society to not care about this or that we are okay with this. And then what does that say about us?

[Esme Jimenez]

As Sidney looked through the archives, she read more and more about how deinstitutionalization played out here in the Seattle area with the closure of Northern State Hospital. And one name came up again and again. Dan Evans.

[Sidney Brownstone]

Hello. Well, this is Dan Evans calling.

[Esme Jimenez]

He's the former governor of Washington State who shut down the psychiatric hospital citing both the shift to community care and the need to cut costs.

[Sidney Brownstone]

Understand you've been trying to get in touch with me regarding the story. Be happy to talk with you.

[Esme Jimenez]

Sidney and I made a trip to the former governor's house in a suburban looking neighborhood of Seattle. We wanted to know how he looked back on his decision to close Northern state more than 50 years ago in light of the mental health crisis of today. Hi there.

[Sidney Brownstone]

Hi.

[Esme Jimenez]

Hi. Governor Evans, how are you?

[Sidney Brownstone]

Good. Great to see you.

[Esme Jimenez]

Evans leads us into a living room with high ceilings and tall windows looking out onto a lake. The former governor, wearing shorts and a collared T shirt, settles into a high backed chair near the fireplace. And if it's not too rude, what. What is Your age today?

[Sidney Brownstone]

97.

[Esme Jimenez]

Nice. So we brought some pictures of Northern State. This is the campus. I wonder if you recall ever if you'd ever been there or visited or walked the grounds. Oh, yes, you did.

[Derek]

Mm.

[Sidney Brownstone]

It was just part of my responsibilities as governor, and I made visits to various state institutions to see physically just.

[Dan Evans]

What they were like Back in the early 70s, around the time of your decision to close Northern State Hospital. That was a really fraught time. And I'm wondering, when you look back on that decision, what emotions does it bring up for you? Is it a source of pride? Is it a source of pain or confusion?

[Sidney Brownstone]

Probably a little bit of awe. But we were at a point where we were beginning to see the end of centralization and the very large multi hundred patient institutions that we had when I became governor. So it was a time of real change, and the change was one that was not without controversy.

[Dan Evans]

So the historical narrative is one where this change began in the 60s with the Kennedy administration to transfer mental health care to these community clinics. But then it's also widely acknowledged across the country that this system of community care never fully materialized. I'm wondering on a local level here in Washington state, what were the obstacles to creating that system of community care?

[Sidney Brownstone]

Well, there was a lot of interest and I think a lot of recognition that just housing mentally ill patients in a very large institution, impersonal institution, was not very good treatment. But I don't think there was a lot of really good knowledge about alternatives. So it was a time of recognizing that we had a problem, but not really knowing exactly what the best answer to the problem was. Mental illness is one of the more difficult challenges we have because it occurs in so many different ways. And it is not something, I think, that people who are in positions of authority where they have that responsibility, are not happy with that responsibility. It's difficult and generally not rewarding in any direct way. Mental illness is a lot tougher than most other challenges that you face.

[Esme Jimenez]

As Sidney and I drive away from the former governor's house, we agree it's not entirely fair to hold one man to account for decisions politicians all around the country were making at the same time, decisions his successors had half a century to fix if they wanted to. But the last thing he said about responsibility echoes in our heads that deep dealing with mental health care is difficult and generally not rewarding in any direct way.

[Dan Evans]

It is recording. I think he did acknowledge, though. He said, no one really wants responsibility for this thing. It's something that everyone struggles with and is really tricky.

[Esme Jimenez]

And I think responsibility, what Evan said to us about that, that the care of seriously mentally ill people is something people in power don't want responsibility for. It cost a lot of money, was complicated to manage, and never delivered satisfying political wins. And once people in government saw that opening, they slipped through it. Once you understand those motivations, it's clear why all of this unfolded as haphazardly as it did, and why these mistakes echoed for decades where without anyone fixing them.

[Will James]

When we come back, we meet someone with severe mental illness who's navigating a patchwork of services on their own with success.

[Derek]

So I have a nice relationship with.

[Will James]

My voices Improvising your way through a mental health crisis. That's next on Reveal.

[Al Letson]

This program is brought to you by Audible. Listen to the new Audible original the Big A Jack Bergen Mystery starring Jon Hamm as the hard boiled private eye cracking his latest case of murder and mystery. Four years after he left the FBI, Jack Bergen is pulled back into the fray by an old flame who persuades him to investigate a homicide and clear the name of an immigrant accused of murder. Conspiracy abounds as a Mexican American community is pushed out in order to build Dodgers Stadium in this story inspired by the real life Battle of Chavez Ravine. Co starring Ana de la Regera as an activist out for justice, Omar Epps as Jack's partner in solving crime, and Alia Shawkat as an intrepid reporter racing to break the story. Plus a cameo from John Slattery as a shady executive. Created by Jon Mankiewicz and directed by Aaron Lipstadt. Listen to a gritty and winding tale that delivers both meaning and mayhem with a solid punch. Go to audible.com the Big Fix and listen now.

[Will James]

This program is brought to you by iPass. I pass works around the world to protect reproductive freedom because everyone deserves the ability to make decisions about their body and their future. When reproductive healthcare is available, accessible and affordable, people and communities thrive. Right now, our fundamental rights are being threatened. For more than 50 years, I pass has resisted and persisted and we need your support. Join our global movement. Donate today to double your impact and support reproductive Freedom. A generous I Pass supporter has offered to match donations up to $50,000. For new supporters, go to ipas.org resist visit www.ipas.org resist. From the center for Investigative Reporting and PRX, this is Reveal. I'm Al Letson. Back in 1989, Lou Middleton was in his 30s, working in a warehouse and living in the heart of Seattle. Lou was listening to a lot of 80s metal and dance music at the time through Speec. In his apartment one day he noticed what sounded like, voices mumbling in the background.

[Derek]

I would turn on a song, and a person would say, oh, gosh, I knew he was gonna play that song. I hate that song.

[Will James]

The voices were criticizing Lou's taste in music. He says at one point, he actually knocked on his neighbor's door to see if it was them complaining from the other side of the wall. They didn't know what he was talking about.

[Derek]

I like Danny Lennox a lot, and I would be listening to the Eurythmics, and then suddenly, right in the middle of the song, I would hear, like, you know, hi, this is Annie Lennox, you know, and we have this special code, and we're trying to send this out to people like you that hear voices. And then I would put on another album, and then that singer would say the same thing, and I'm going, like, how is this happening?

[Will James]

Liu was experiencing the early stages of psychosis. As Liu got more stressed, the voices came to him in other forms, not just in music, but also in the buzzes or hums of appliances. They said they were after him. He started to believe them.

[Derek]

I was just completely consumed. Every movement, everything I was doing was because of the voices.

[Will James]

He was eventually diagnosed with bipolar disorder with auditory hallucinations. Reporter Will James talked to Lou because his story is an example of someone navigating their mental illness towards a recovery that works for them, even when federal and state services fall short. Will starts at a low point in Lou's journey, when he was living in the woods in Washington state.

[Esme Jimenez]

In each story of recovery from serious mental illness that I've come across, there's a moment that shocks someone out of the loop. They're stuck in a moment. They can step outside their illness and start to see it for what it is.

[Derek]

I was running from nothing. I'd hear, like, he's over that way. Let's go follow him. And the more I thought about maybe people chasing me, the more it became people chasing me.

[Esme Jimenez]

For Lou, it started with a bite wound. He says at some point while he was homeless, he got in a fight. He doesn't remember the details, but somebody bit his arm. And that night, he happened to see an ex girlfriend, someone he had kept in touch with over the years, someone who still looked out for him, tethered him to the mainstream world.

[Derek]

She's the one that got me to go to the hospital.

[Esme Jimenez]

This ex girlfriend convinced Lou to get the bite wound checked out, and then she convinced him to stay for a psychiatric evaluation.

[Derek]

They asked me these questions, and I shared these things about that were going on I can't remember exactly. It was. They were just very delusional answers. And when they came back for the assessment, it was like literally telling me I was crazy. I was like, wait a minute, you know, how do you know? You weren't there and you're trying to tell me that this is going on. So I found myself strapped on a bed going up to Harborview 5, I think it is.

[Esme Jimenez]

He's talking about Harborview Medical center, one of the only hospitals in the Seattle area with a specific unit for psychiatric emergencies. Lou says he thought he was living through Invasion of the Body Snatchers and that the antipsychotic medication they were on offering him was poison. But even in the middle of his delusions, he would have what he calls window periods when he'd have more clarity. One of these windows happened to open while he was in the hospital and he agreed to take the meds.

[Derek]

It started like helping to calm the voices. Didn't go away completely. It just kind of brought it down to the point of where they weren't so loud.

[Esme Jimenez]

Lou says his medication eventually gave him tardive dyskinesia, a possible side effect of antipsychotic meds that causes facial tics and other involuntary movements, and he had to stop taking it. Other meds actually seemed to make the voices louder. Eventually, Lou got off medication entirely. But for a while, at least, early on, the medication opened up some space for Lou, gave him a reprieve from the voices, even if it didn't squelch them entirely. He was placed in a federally funded housing program at the hospital, and from there he was able to move into his own apartment. Lou's life had changed radically within a couple years. He went from homeless in the woods to having an apartment and a car. But the voices were not done with him.

[Derek]

I was hearing somebody, you know, Lou, Lou, you know, help me, help me, please. These people are trying to kidnap me. And I said, well, who are you? They said, well, I just heard about you, you know, and there's this channel that we can communicate with each other on. Please come and help me. I said, well, how do you look? He says, you'll see me. Please hurry. Don't ask all these questions. I got brown hair, okay? I go, yeah, but where are you going to be? He goes, hurry, will you?

[Esme Jimenez]

The voices sent Lou on a rescue mission to the Paramount Theater in downtown Seattle. And then when he got there and didn't find anyone, they sent him to the Space needle about a 10 minute drive away.

[Derek]

So I'm driving over and looking around that Space Needle trying to find anything suspicious. And he's like, oh, they took me up to Capitol Hill. I'm up on Capitol Hill. And meanwhile, I'm looking at my gas tank, and it's, like, running low on gas. And I'm thinking, like, wait a minute here. Why is it that you know where you're at?

[Esme Jimenez]

For years at that point, the voices had ruled Lou's life. Whatever they told him became his reality. But this time, he had questions, and the voices did not like that.

[Derek]

It's just like the first thing. He says, you son of a. I'm gonna kill you. And I said, well, how can you kill me if you're being kidnapped? I mean, this doesn't make sense. He says, I'm gonna kill you. And I said, fine.

[Esme Jimenez]

Lou says he went home and waited with a baseball bat for someone to try to kill him.

[Derek]

I left my back door wide open, and I said, come on. I'm tired of you threatening that you're going to kill me. And since you have so many people with you, I'm here. Come so here. About a couple hours passed, and I said, well, where are you? Well, we have something to do, but we will be there soon. I said, you know, why am I going to leave my door open to some guy, some idiot that's busy doing things? And then the next morning, you're not going to be here, but I'm going to continue leaving my door open waiting for you to be killed. I said, that sounds real stupid. And then it just stopped. It stopped. There was no deaths. There was no nothing. It was just like the reason just completely stopped what was going on. And I thought, wow, you know something? There's something to what's going on here. I said, how much is it? Is it me?

[Esme Jimenez]

Anosognosia is the scientific term for being so sick you don't know you're sick. From ancient Greek, it roughly translates to disease without knowledge. And in psychiatry, the opposite of anosognosia is insight, the realization that these experiences are coming from inside you. For Lou, it took a connection with a friend, his ex girlfriend, who was there at the right moment. And then hospitalization, medication, housing all of this created the conditions for Lou to come to this realization for himself. From there, Liu was able to build on that insight. Lou has an autoimmune disease and learned that eating certain foods could cause it to flare up, and that would make the voices louder and meaner. He started paying a lot of attention to his diet and found the voices were like a meter Telling him how well he was taking care of himself. He learned the voices reflected his own feelings. If the voices were cruel, it meant that somewhere inside, Lou was being cruel to himself. And so the voices taught him to be gentler with himself. At one point, Lou came across the hearing voices network, A community of people who hear voices and support each other. Lou wanted to make sure no one else like him ever went through what he did. Running from the voices alone. He got a job with the downtown emergency service center. Lou was there for 25 years, becoming the longest serving certified peer counselor in Washington state history. He spent years leading support groups for people, many of them homeless. This is Lou.

[Bethany Anderson]

Hello. Nice to meet you.

[Esme Jimenez]

On this day, lou is visiting DESC's Lou Middleton drop in center for the first time since he retired a few years ago. How does it feel to be here?

[Derek]

Yeah, well, colors made a big difference. I remember that we were talking about adding colors to kind of brighten up. This used to be my little office.

[Esme Jimenez]

This was your office right here?

[Derek]

This is my office. I think one of the fun things was music. Playing music in here. They love music.

[Esme Jimenez]

You do? Lou would lead his support groups in a back room of this center. People would share stories with Lou and with each other about their voices. It was a gradual process of getting people to see these voices not as outside entities, but as parts of themselves, Parts they had some power over.

[Derek]

I would try to be very positive with my voices. Okay, look, you know what? You've done that before, and I'm not going to get bothered by it. I understand you're having a difficult time right now, and I need to listen to what you're saying. And I'd hear this. Thank you. Wow, you've changed, you know, that kind of thing. So I have a nice relationship with my voices. This is my experience. Others have their own experiences that they're dealing with their own life. But there is a path that they can walk along. But the biggest part of it is being able to learn how to listen to yourself.

[Esme Jimenez]

For Lou, and for lots of people with serious mental illness, recovery does not mean the symptoms are gone. If you don't mind me asking, are you hearing voices now as we sit together in this room, or are they quiet right now?

[Derek]

Sometimes they're talking, but most of the time they're kind of subdued. They're quiet. And I just kind of hear, like, in the background, them saying like that. So it's interesting. I feel that they develop this fear that I'm separating from them and they start calling out my name. And and it's like, hey, you're in the same place in the brain. I said, you haven't moved anywhere. They're not perfect, we're not perfect. And if we're going to learn how to work with our voices, we have to realize they're imperfect. And then we have to realize what we're doing to our own self.

[Will James]

Starting in 2024, policymakers in King county was where Seattle is are rolling out a plan to build five new crisis mental health centers and expand psychiatric hospital beds. And staff leaders call it an attempt to undo mistakes made decades ago, during the age of deinstitutionalization when real community based solutions failed to material Lost Patience is a production of KUOW and the Seattle Times. You can listen to the full Lost Patience series anywhere youe get your podcasts and there's so much more. Will and his reporting partners expand on Adam Iran's story, dive deeper into the national history of mental health care and ask people who experience psychosis what it feels like and where the system goes wrong. The Lost Patients team includes reporters Will James Sidney, Brownstone and Esme Jimenez. It was edited by Liz Jones. Our lead producer for today's show is Najeeb Amini. Jenny Casas edited the show. Nikki Frick is our fact checker. Victoria Baranetsky is our general counsel. Our production managers are Steven Rascone and Zulema Cobb. Score by BC Campbell. Sound design by the dynamic duo Jay Breezy, Mr. Jim Briggs and Fernando My Man Yo Arruda. That help from Aisha Wallace Palomares. Our interim executive producers are Bret Meyers and Taki Telenides. Our theme music is by Camarado Lightning. Support for reveals provided by the Riva and David Logan foundation, the John D. And Catherine T. MacArthur foundation, the Jonathan Logan Family foundation, the Robert Wood Johnson foundation, the park foundation, the Schmidt Family foundation, the Hellman foundation and by listeners like you. Reveal is a co production of the center for Investigative Reporting and prx. I'm Al Letson and remember there is always more to the story.

[Esme Jimenez]

From prx.