Focus: Adults in the Room - Lost Patients: Opening

Episode Date: April 2, 2024

In the middle of the last century, a movement to free patients from state-run psychiatric hospitals swept the U.S. This movement — deinstitutionalization — is widely blamed for seriously mentally ill people ending up on the streets. The real story goes much deeper than a loss of psychiatric hospital beds. It's about how incentives and decisions half a century created the dysfunction many people with serious mental illness are lost in today.See omnystudio.com/listener for privacy information.

We all remember this song. It made it all seem so simple. And turns out it's not. Who writes, influences, and kills bills, it gets messy. I'm Scott Greenstone. And I'm Libby Dankman. On sound politics, we tell that story, the inside track on how policy gets made in this Washington and the other one, and how it impacts you. Listen now on the K-O-W app or wherever you get your podcasts. A warning to listeners. Lost patients is about serious mental illness. It's true that horrors unfolded at Northern State Hospital, the psychiatric hospital run by Washington State in the Valley North of Seattle.

Insulin comas. Transorbital lobotomies. We heard about some of that from Joanne McKinnis, who started as a nurse at Northern State in the 1950s. Now in her 90s, and living in a retirement home near the hospital, she still wrestles with those memories. But there's one thing Joanne's sure about. As the years rolled on, as the 1950s became the 1960s,

Northern State got better. I'm talking about the development of the first psychotropic drugs. And then there was a lot of research that was going on. And I felt good about Northern's part in that. These new antipsychotic drugs seem to calm people with, psychotic disorders and reduce their symptoms. As these drugs swept the country, the more brutal treatments faded away, and a new optimism set in. For decades, the best psychiatrists could hope for was to contain psychosis. But now, they believed, they might actually cure it. The doctors were

evolving, too. This was the 1960s, a revolutionary time. And the little gods who ruled over the campus were open to new ways of thinking. You see just more progressive ideas about what mental health treatment should look like coming to the fore. Sydney Brownstone, an investigative reporter with The Seattle Times, spent months delving into Northern States history to try to understand how our modern approach to psychiatric care took shape. The 60s at Northern State included something called the open door policy, which allowed patients' freedom of movement, which wasn't always the case. I remember talking to Joanne McKinness when she started. started in 1954, most of the wards were locked. Did that change over time?

Oh, yes. Yeah, eventually almost all of them were open. Why do you think that change happened? I think it went back to the education of staff. We wanted it to be different. We wanted to be proud of what we were doing. For supporters of this open-door policy, it wasn't just the act of physically unlawful.

locking doors. It was a fundamental shift in thinking, finally seeing the patients as fully human, giving them enough freedom and responsibility that they could more easily reintegrate into society. But just as Northern State was changing, this same revolution in thinking set the stage for Washington State's leaders to shut the asylum down, just a few years later in 1973. The idea was that after a century of treating patients in these psychiatric hospitals, it was time to turn away from this model entirely and build a new system that cared for patients closer to home in their communities. This movement called deinstitutionalization has erased 84% of state psychiatric hospital beds in the U.S. over the past 50 years, a near extinction

of a whole style of medical care. Most of those beds vanished during a single decade from 19, 70 to 1980. Today, deinstitutionalization is widely viewed as one of the most disastrous policies in U.S. history. As a reporter, when I talk to regular people about the rise of seriously mentally ill people on the streets, it's conventional wisdom that deinstitutionalization is to blame, that we once had places for these patients to go, but then we shut them down and set everyone free. But the real story of deinstitutionalization is to blame, that we once had places for these patients to go, but then we shut them down and set everyone free. But the real story of deinstitutional,

institutionalization goes so much deeper than just we used to have beds and now we don't. This story is about exactly how and why it failed. How a set of values and incentives set in motion massive disruptions to the way the poorest and most vulnerable people in our society survive. It's about how deinstitutionalization is the origin story of the churn. I'm Will James from KUOW and the Seattle. In many times, this is lost patients. Episode 4. Opening.

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. In the 1960s, two ideas of mental health care were colliding. For decades, society had leaned on psychiatric hospitals to hold patients it saw as having a little hope of getting better, to separate them from everyone else, sometimes hide them for the rest of their lives.

This is called custodial care. But President John F. Kennedy was pushing a new model, getting patients better, and returning them to society as quickly as possible, with the help of these new antipsychotic drugs. When Kennedy's sister Rosemary was 23, she underwent a lobotomy, leaving her mostly unable to walk or talk.

She spent the rest of her life in institutions. Kennedy, informed by this family history, challenged states to get people out of custodial care and treat them closer to home. He envisioned a country where, quote, the cold mercy of custodial care would be replaced by the open warmth of community. Kennedy's 1963 Community Mental Health Act set aside $150 million to build and staff 1,500 community mental health centers around the country. 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. Here's a piece of copy that was rushed. Two million was torn off from the United Press and Dallas. President Kennedy has been shot in...

Kennedy was assassinated three weeks later. This was the last bill he signed. President Kennedy died at 1 p.m. Northern State Hospital embraced Kennedy's vision. It wasn't just the open-door policy. The hospital shifted its entire purpose to getting patients discharged and back into their hometowns

as quickly as possible. A Seattle Times article from the 60s summed up this new way of operating. Quote, patients are admitted, given drugs, stabilized, allowed some freedom over their daily routines, some visits home, then as soon as they're ready, released.

The rhythm of the hospital changed. In 1955, a little after Joanne started as a nurse, Northern State was at its peak with 2,200 patients at any one time. By 1970, that number was down by almost two-thirds to 700 patients at a time. There was almost one employee for each patient, and the numbers kept dropping. Washington had three state psychiatric hospitals in three corners of the state, northern, western, and eastern, and all three saw their daily populations shrinking. With the advent of new treatment techniques, medications, and increasing emphasis on prevention and early treatment in the communities, drastic changes began to occur. State leaders took stock of these developments at a Senate committee meeting in 1973.

Average daily populations dropped from a high of 7,500 in 1955 to the present level of to psychiatrists. To psychiatrists, this was all part of the plan of deinstitutionalization. There were still thousands of people admitted to the state psychiatric hospitals every year. They were just cycling back out much more quickly, so there were fewer patients on the campuses at any one time. But their bosses in state government saw it differently. The Northern State Hospital staff complement remains at 481,

serving approximately 300 patients. The Ferdian costs at Northern have risen correspondingly from $22.45 last year to $35.78 now. It's the classic tension between the people with the green eyeshades, the bean counters, and the people providing the care because state officials were just looking at the declining numbers and the rising costs of care and going, we're not getting enough bang for our buck.

And the people providing the care, we're going, No, you're getting bang for your buck. You're just not seeing it. The person presiding over all this transformation in Washington State was Governor Dan Evans. He is the kind of man who makes us proud to be Republicans. Around this time, Evans was in his early 40s and having a moment. He gave the keynote speech in the 1968 Republican National Convention. He is articulate. Oddly enough, there is background. by training and education is that of a civil engineer.

Evans was an engineer before he was a politician, which fit with Washington State, where the economy revolved around the airplane manufacturer Boeing. He was known as cool-headed and soft-spoken, a moderate Republican back when Washington was more of a swing state. Both Richard Nixon and later Gerald Ford considered Evans a possible running mate. It's fair to say no politician from the Pacific Northwest has come closer to being president. Let those who offer old promises step aside and let those who promise new opportunities

step forward. But by the early 70s, Evans was just trying to hold Washington State together. Because of problems in the airline industry, Boeing laid off more than half its workforce. So many jobs disappeared that two real estate agents put up a billboard that said, will the last person leaving Seattle turn out the lights? Washington's unemployment rate hit 14 percent, the highest in the U.S. All this added to what the Seattle Times called the toughest budget crisis in state history as tax revenue cratered. It wasn't long before Evans trying to balance the budget started eyeing northern states,

the smallest of the state's three psychiatric hospitals with a shrinking patient population and the highest per patient costs. So you have the governor in particular saying it's time to wind this down. It's a massive cost and it's time to transition to community health care, which is supposed to be better for the patients. The biggest opposition to that argument comes from the residents of Cedro Woolley, the town where Northern State is located, and their opposition is an economic argument. They're saying the hospital is the biggest employer in our area. What are we going to do if it closes? Hundreds of jobs will be lost.

When Governor Evans argued for closing Northern State, he cited both the national movement away from psychiatric hospitals and toward community care and the potential cost savings. The issues of deinstitutionalization and money blended together. I think a law politicians started calculating out what could be saying. Chris Hudson is a social worker and academic who spent decades at Salem State University in Massachusetts studying our systems for caring for seriously mentally ill people. He says deinstitutionalization started with a civil rights agenda, freeing patients who were warehoused at psychiatric hospitals. But soon, a second motivation got mixed in as leaders in state governments saw an opportunity to free themselves from a financial and political burden.

Chris says these incentives acted like fuel, accelerating the push to close psychiatric hospitals. Beginning in the early to mid-60s and 70s, those dramatic declines in the psychiatric beds, it was precipitous. There was a rush to get people out. Governor Evans' plan was to transfer some of Northern States patients to one of Washington's remaining psychiatric hospitals, Western State, and send the rest to community care. Washington had been building out a system of local treatment centers for a few years, and by 1973 had a program in every county of the state. But the system had never been tested in this way,

and some lawmakers started to wonder whether it would hold up. I just personally cannot buy the fact that the community mental health program is at this pretty ready and able to accept the case, the mentally ill, the people that really need to care. State Senator Lowell Peterson was a Democrat whose district covered Northern State. And I, frankly, can't readily adapt myself or my thinking to the fact that we're going to displace some four or five hundred people and automatically transpose them overnight from northern to Western, and the community of mental health centers are going to take care of all of our.

problems at a less expense. People in Governor Evans' administration were adamant. Community care was ready to pick up where Northern State left off. For the purposes of our budget discussion now, we again recommend the closure of Northern State Hospital as a state psychiatric hospital by the end of calendar year 1973. In the state archives and old newspapers, there's not much evidence that a patient rights movement clamoring for community care was driving the closure. of Northern State. Instead, the historical record is dominated by the national attitude that moving away from psychiatric hospitals was inevitable, plus state officials' concerns over money. This is a detail of the projected savings of the closure of Northern. Governor Evans got his wish.

Northern State Hospital would shut down by the end of 1973. According to newspaper stories from the time, Evans' administration thought closing the hospital would save something like $14 million over two years. And of those savings, some went back to Cedra Woolley, the town where Northern State was, to ease the economic pain of the closure. And only a fraction was reinvested back into mental health. Let's just be clear, $14 million would not have saved the mental health care system at all. But it does speak to our priority. I mean, granted, the state was going through a period of austerity. It was slashing social service programs left and right.

But you would think because such a fuss had been made about creating this new system of community health care that we would prioritize putting whatever money we had towards that promise. A front-page story in Cedro Willey's local paper marks the hospital's closure. Most of the article is about employees scrambling to find new jobs. It says nothing about the fates of the patients. It was kind of sad. I hated that it was closed. Joanne was part of a group of nurses who got transferred to one of Washington's two remaining state psychiatric hospitals, Western state, about a two-hour drive to the south.

I felt like the patients weren't taking care of. There wasn't the follow-up in the support system. knocked out. I wish it would have stayed open and we could have done more. What happened to the patients? They were dispersed. We had patients from northern that went to Western. We didn't get a chance to fall through with them or anything, but they did. And some went to Eastern. It depends too on where they were originally from or where there was. beds available. Some went into the community.

Some were put on the streets. It would be years before people started taking stock of what happened to the lost patients of Northern State. Call your friends, your partner, and maybe a babysitter, because Seattle Restaurant Week is here. I'm Brandy Fullwood, host of Seattle Eats. And on the latest episode, Seattle writer Harry Cheatel has been doing the math, so you don't have to. We'll tell you about the deals, dishes, and drink pairings worth checking out this Seattle Restaurant Week. Listen to Seattle Eats on the KUOW app or wherever you get your podcasts. As Sydney sits with former nurse Joanne in her retirement home, in the same valley

as the ruins of Northern State, on a whim, she asks about a particular patient, one among thousands who passed through the hospital while Joanne was there more than half a century ago. Did you ever know anyone named Phil Diro? Oh, he is. You do? Oh, absolutely. Oh, my gosh. He is.

Okay. Sydney had read about Phil in old Seattle Times stories. He was the exact sort of patient deinstitutionalization was supposed to rescue. Phil's parents committed him to Northern State when he was 16. hospital records say he had above-average intelligence, but he was, quote, overly talkative and overly concerned with other people's business. Phil would later tell a reporter he was sent to Northern State on a bum wrap just for being noisy and talking a lot. He talked continually. He just went on and on and on. And how he managed to cram so much information into that hit of his.

and where he got it, we do not know. But you could walk on the grounds, and I swear, he knew what your name was, who you were married to, how many kids you had, no matter what, where you lived. He just had this appetite for knowledge about each individual employee. It was just amazing. Three years after he was committed,

Phil was lobotomized. He was 19 years old. It didn't stop him from talking a lot, but it did give him lifelong neurological problems. He got seizures and had trouble holding his bladder as a result of that operation. In some ways, his case was kind of a classic case of someone who could probably be independent but was stuck in an institution and couldn't get out and had been there for his entire adult life. stay at Northern State for 26 years until he was in his 40s. In the waning days of the hospital, Phil wrote letters to lawyers begging to be released. Finally, the American Civil Liberties Union took up his case, and he was freed in 1971, as politicians debated whether to close Northern State. Do you know what happened to him when Northern was closed? I understood that he went to Seattle someplace.

But I, other than that, I don't know. Phil kept popping up in news stories once he was released, but the focus of the articles changed. He was no longer a symbol of someone who didn't belong in a psychiatric hospital. He was a symbol of the lost patients trying to survive in the world deinstitutionalization had created. Even when you have someone who's relatively high functioning, like Phil Diro, it's still, still a struggle on the outside of the institution, not because the institution let him out, because of the world and the conditions that we created outside of the institution.

In 1979, a reporter caught up with Phil. Phil was living in a $100 a month apartment in a building he had nicknamed the Heartbreak Hotel. It was on a man-made island in the middle of Seattle's port, surrounded by industrial plants, train tracks, and parking lots. Phil was becoming a fixture of Seattle streets, a local character. In photos, he has a mustache, thick glasses, a fedora, and a pipe sticking out of his mouth. He spent his days wandering the city, chatting people up, carrying a bag that had 17 pipes in it. When one pipe got too hot, he said, he'd put it away and pull out a new one.

Phil was struggling to live on $226 a month in Social Security. A caseworker spent weeks trying to connect Phil with resources, but Phil's particular problems didn't fit neatly with any of the help that was available. Each agency just referred him to another agency. The caseworker said Phil was one of the toughest cases he had ever seen. At one point, Phil's friends threw a Halloween party to raise money for him. Phil dressed up as a mafioso. The party raised $375.

years after Phil left Northern State, this is who looked out for him. Not any kind of system, just a cobbled together network of people he had managed to charm. What does Phil Diro's story represent? What does it tell you? I mean, it kind of tells of hardship on both sides of the institutional question, right? He was someone who was locked up, lobotomized, didn't need to be there. probably for his whole life. Like he lost out on so many years of his life. And, I mean, he was left with permanent damage as a result of the lobotomy. And then on the other side of being let out,

he had his freedom, but it was a very marginal existence. He didn't have a lot of money. He had to move every so often. He was thrown out into a world that had very few resources for the problems that Northern State gave him. Phil's saga is just one example of a whole new genre of article that appeared in newspapers after Northern State closed. A string of stories by journalists trying to figure out where the patients ended up. Like this one, from 1974, about a year after Northern State closed, parents of a 22-year-old woman who had been a patient at Northern State

struggled to care for her at home. Quote, her parents were assured that, help for her would be available in the community. Her father was told glowing stories about community-based mental health centers, but he had no idea where to find them. Desperate, he called Northern State for help, even though it had been closed for more than a year. The call went to the campus's electrical plant.

By the early 1980s, it was clear all around the U.S. that deinstitutionalization had gone disastrously off course. From National Public Radio, this is Horizons. This NPR story from 1984, documents of phenomenon people were seeing in cities all around the U.S. at that time. A rise in people who seemed seriously mentally ill and were living on the streets. In this edition of Horizons, Frank Stasio 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 follow. Deinstitutionalization has been going on for an awful long time. There's been a lot of time to figure this out, isn't it? Well, you think we'd figure it out, but in fact, the deinstitutionalization has been a horror. Psychiatrist E. Fuller-Torrie spoke with NPR in 1984.

Fuller-Torri would later become a leading voice calling for more involuntary commitment and a foil for patient rights groups. But back then, he was reflecting what a lot of mental health workers were seen. Deinstitutionalization itself was perfectly legitimate. A lot of these people can live outside the hospital. However, we failed to set up programs to take care of them. In 1980, President Jimmy Carter

tried to revive Kennedy's vision by signing the Mental Health System Act, which set aside more federal money for community mental health centers. but less than a month later, Carter lost re-election to Ronald Reagan, who repealed Carter's bill and slashed funding for mental health care. The community mental health centers that did exist provided a mishmash of different types of care. The lattice work of agencies, rules, and entitlements.

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. Chris Hudson, the social worker and academic, says they focused on treating what some call the worried well, people who live pretty normal lives but want treatment for things like depression and anxiety. The seriously mentally ill, they often had to chase down.

They would miss their appointments, and it was a hassle, and they were very difficult to serve for lots of different reasons. The seriously mental ill and the people coming out of the state mental hospitals were not popular patients, so that seriously mental ill tend to fall by the wayside. The community mental health centers, with only rare exceptions, have never picked up and taken care of the seriously mentally ill. Fuller Tori again, talking with NPR.

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 illness. 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.

In some cases, the side effects were so far. brutal, patients couldn't tolerate them. Stiffness, trouble walking, uncontrollable restlessness, feeling sedated, weight gain. And the drugs could only work if patients took them. Some suffered from anisognosia, not believing they were sick. And others couldn't make or keep appointments. In these cases, community care was not designed in a way that actually reached the people who needed it. 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 U.S., homes for the poor. worst 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. Newspapers documented these closures. Well, it's interesting because the reporters would trace these patients to group homes or SROs, for example. And then a few months later, they'd follow up with another article saying that the group home is closing down.

And so you see this story over time of the refuges outside of the institution disappearing too. This is an era of massive change for the most vulnerable people in our society. And yet, that wasn't really felt by middle class or otherwise comfortable people at all. So even during this time of great change, it kind of was like motion under the surface. 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.

Sydney was searching in the Seattle Times archives for evidence of what happened to the lost patients of Northern State when she stumbled on a missing link, connecting the era of deinstitutionalization to the world of today. Let's go to December 20th. Oh, wow. The headline of this piece is The mentally ill, victims of an experiment that failed.

And this is a piece by an editorial writer. Crowds, this is how it begins. Crowds rush past them on downtown streets pretending not to hear their confused or angry chatter. They are studiously avoided when they wander through neighborhoods. Occasionally when they become a nuisance or create a disturbance the police are called. 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. 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 same. cycle begins again. It froze me. A lot of things were flooding my brain at once. Like, holy shit.

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 also like, what is even the point of my job then? If I keep writing the exact same sentences that someone 40 years ago was writing, why do I exist? Why are we doing any of this? Because clearly presenting people with the same information over and over and over again isn't doing anything. 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? That we have been reading these same stories in our newspapers in every American. American city for 40 years, and we've decided that that is okay. It raises a question. How do the people who made these decisions half a century ago look back on them now? Soundside brings you beyond the headlines with news and conversation rooted in the Pacific Northwest. I'm Libby Dankman. Every week, I sit down with local journalists for SoundSide's front page, where we give you a shortcut to understanding the latest news and cultural moments and how they affect us here in the Puget Sound region. It's all here on Sound Side, on the radio or streaming

Monday through Thursday at noon and 8 p.m. on KU.O.W. on the KUOW app or wherever you get your podcasts. You've been trying to get in touch with me regarding. I'd be happy to talk with you. The man who almost sort of might have been president, the man responsible for the most obvious act of deinstitutionalization in Washington State's history, lives in a house you can just drive up to, in a suburban-looking part of Seattle. As Sydney and I walk down the driveway and stand in front of the door, our hope is to ask former Governor Dan Evans

how he views his decision to close Northern State today in light of what's going on in Seattle's streets. Hi, hello. Hi, Governor Evans. How are you? Good. Good to meet you. Good to meet you. Hello. I'm Sydney. Brought your newspaper. Okay, good. Evans leads us into a living room with how much. 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. Um, and if it's not too rude, what, what is your age today? 97. Nice. So we brought some pictures of Northern State Hospital. This is the campus. I wonder if you recall ever, if you'd, if you'd ever been there or visited or walked the grounds. Oh, yes. You did? It was just part of my responsibility as governor, and I made visits to various state institutions

to see physically just 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?

Probably a little bit of all. But we were at a point where we were at the beginnings of a more localized, attachment to mental health and its treatment. and we were beginning to see the end of centralization and the very large, you know, multi-hundred patient institutions that we had when I became governor. So it was the time of real change, and the change was one that was not without controversy.

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. It was impartial measures. I'm wondering on a local level here in Washington State, what were the obstacles to creating that system of community care? 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 a 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. And so it was a time of change, but during a time of change like that, you start down a different path or different and multiple paths seeking better answers. Sometimes you find them, sometimes you don't. What Evans remembers most about this period is the national movement, away from psychiatric hospitals like Northern State and how in light of that movement,

it made sense to close the hospital. But Sydney and I came with letters from Washington residents from around the time Evans was making that decision. And those letters foreshadowed some of what was to come decades later. This one really just stuck out to me. And so I just wanted to read it.

It's a letter a Washington mother sent to Evans while deinstitutionalization was going on. My son and daughter have had three complete mental breakdowns and have been committed to Western State Hospital, and after four to six weeks have improved to the point where they could get along nicely at home, but they have stopped taking their medication and soon after have had recurrences. Approximately a year ago, my son had another relapse and was in a horrible condition. He kept driving his car around crazily, had many arrests. It's a miracle he didn't kill someone.

no one can understand the suffering I had with him prior to this. How does that make you feel today to hear that? Well, you have hundreds and hundreds of problems challenges when you're governor, many of which you can see the problem fairly clearly and find and have a solution that really is a solution, 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. As Sydney and I drive away from Evans' house, we agree. It's really hard to hold one man to account for decisions politicians all around the country were making at the same time as him. Decisions, his successors, had half a century to fix if they wanted to. But that last thing he said about responsibility echoes in her. our heads. Oh.

It is recording. 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. Responsibility. What Evans said to us about that, that the care of seriously mentally ill people is something people in power don't want responsibility for.

I think that's the real story of deinstitutionalization. It started as a civil rights movement, but ultimately it created an opening for people in government to escape a responsibility they didn't really want. A responsibility that 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 without anyone fixing them. Here's how I see deinstitutionalization now. For a century, we lived in a country where pretty much one entity, the state, took responsibility for seriously mentally ill people.

And deinstitutionalization was the moment that ended. The state, which was once a provider of care, with its own army of psychiatrists and nurses in state-run hospitals, became more of a funder of care, giving out money to non-profit contractors and local programs to handle things. They each oversaw their own piece of it, but it was nobody's job to make sure the sickest patients, the ones who needed long-term, day-to-day care, ever got that. After Northern State closed, social services, including mental health care, just became totally atomized. So now we have all these nonprofits that are directly treating people and caring for them, but government is several steps away. Today, you can see this fragmented responsibility spread out across jails, prisons, emergency rooms, what's left of the state psychiatric hospitals.

and in homeless shelters, like Seattle's downtown emergency service center, D-E-S-C, a perpetually stretched nonprofit known for taking on the city's most difficult cases of mental illness and substance use. On the sidewalk outside DESC, you can find a bronze leaf embedded in the cement with a name etched on it, Phil Dyero. Advocates put it here to memorialize him. after he died in 1999. By then, Phil was a sort of legend on Seattle's streets, a character who talked himself into lots of people's lives and memories. And it fits that his saga would start at Northern State Hospital

and end here, outside one of the many broken-up islands of refuge that replaced him. Just a short walk from here is the spot where Adam Orant, who he met at the best of the best of the beach, beginning of this series was dropped off after he was released from one of Washington State's remaining psychiatric hospitals. What happened to Adam next shows the depths of our failure to build something new after deinstitutionalization. Coming up on lost patients, we returned to Adam in 23, half a century after Northern State closed, mentally ill, homeless, and ejected into a world we created.

Lost Patience is a production of KUOW Public Radio in the Seattle Times in partnership with the NPR Network. You can support lost patients by investing in the local newsrooms and specialized beats that make this sort of storytelling possible. Please consider joining and subscribing at kUOW.org in SeattleTimes.com. This episode was reported, written, and produced by Sydney Brownstone, Esme Jimenez, 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 Grenier's. Our music is by B.C. Campbell. Mixing by Jason Burroughs. Logo and branding by Alicia Villa and Michaela Giannati Boyle. Thank you to Seattle Times videographer Lauren Frone for sharing the tape she gathered and to Seattle Times photographer Karen Ducey, who illustrated Northern State in the Seattle Times. Thanks as well to NPR for sharing tape from 1984 to former NPR reporter Frank Stachio for reporting that story into former Seattle Times journalists Marjorie Jones and Steve Johnston

for their 1970s reporting on serious mental illness, homelessness, and Phil Diro. Thank you finally to Joanne McKinnis, Chris Hudson, and Dan Evans for sharing your stories and expertise. Hi, I'm Monica Nicholsberg. And I'm Joshua McNichols. We host KOWW's Economy Podcast, Booming. For decades, the University of Washington, has received more federal research money than almost any other public university.

And the research that's come out of the institution has fed the growth of the region's biggest employers. On the latest episode, what could cuts to federal research funding mean for Seattle's future economy? Listen to booming on the KUOW app or wherever you get your podcasts.