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How WA's mental health labyrinth claimed a life
Seattle Times - 10/23/2023
Oct. 22--Adam Aurand was at yet another crossroads.
He had been homeless and dealing with severe mental illness and substance use disorders for years, ricocheting between emergency rooms and jails but never finding stability.
Finally in 2022, he was sent to Western State Hospital, the largest psychiatric facility in Washington. He spent nearly a year there in treatment.
Now, Adam was set to be discharged to a homeless shelter in Seattle'sPioneer Square neighborhood.
When his mom, Heidi, and his sister, Bethany Anderson, found out, they begged for more time, alerting a Western State social worker that Adam was acting strange during their phone calls and commenting about apparent hallucinations.
"My brother is not in a stable mind frame to make decisions that are in his own best interest," Bethany wrote in an email days before her brother's discharge.
"The minute he hits the street, we won't hear from him or see him possibly ever again," she added.
Nearly a month later, 40-year-old Adam was dead.
ADAM'S FINAL YEARS, and his death, illuminate the stark reality many people with serious mental illnesses and their families face. The system -- a patched-together labyrinth that spans the health care, public safety and housing worlds -- can materialize in moments of crisis, but it struggles to provide the comprehensive care needed for recovery over a lifetime.
Adam's diagnoses were ever-changing and complicated by drug use. He also frequently refused care -- a trait that often comes with mental illnesses. In response, those who were meant to help him said their hands were tied, pointing to Washington's strict laws outlining when the state can step in and force mental health treatment.
It felt like no one took responsibility for truly helping Adam get better, Heidi said. Instead, her son confronted a series of one-way streets: Jails detained and housed him, and hospitals temporarily treated him, but there was no clear collaboration between these entities.
This dissonance -- the system's inability to guide someone from one step to another -- means those patients who are the most vulnerable, with complex, intensive needs, are the ones failed most by Washington's mental health landscape. And they never reach the end of the maze.
ADAM'S CHILDHOOD was shaped by chaos.
With one younger sister and one older brother, he grew up as the middle child in Georgia. He, like his father, had a genetic disease called osteogenesis imperfecta or brittle bone disease.
Adam's sister, Bethany, remembers a time he tripped over a rope in the family's backyard.
"Normally, you might skin your arm; you might have a little blood coming out. The bone popped through my brother's arm. That's how bad it was."
He lived in a "precarious state," Bethany said. At times, he was prescribed morphine and other opioids for the pain, medications his family believes laid the foundation for his future addiction. There was also trauma -- from the disease and from domestic violence the family experienced, Heidi said.
Adam, according to his family, made the best of things.
He was gifted with machines, often disassembling and reassembling broken lawn mowers, a skill he later put to use working in Seattle auto shops.
He was also capable of picking up instruments by ear; he played guitar and recorded rock songs with his brother, who played drums. His family describes him as kind and soft-spoken, with a silly sense of humor.
But in his 20s, Adam's behavior started to change.
"It would have been the age my mom and I found out later that the onset of schizophrenia set in," Bethany said. Though at the time, the family thought his symptoms were tied solely to drug use.
Speeding tickets and minor traffic violations in Oregon escalated to charges of trespassing and theft in Washington. Adam started bouncing around between relatives' homes and eventually landed on the street.
Over the course of his lifetime, Adam was diagnosed with a variety of mental illnesses, such as schizophrenia and schizoaffective disorder, substance use disorders, as well as anxiety and depression. Mental illness is notoriously difficult to diagnose; unlike physical illness, there's no clear exam or test, and symptoms often overlap.
There were opportunities, over and over again, for the system to intervene and get Adam treatment. He had countless interactions with courts, jails and mental health professionals, including at least 36 run-ins with law enforcement in Oregon and Washington, often for trespassing or property crime. But he, like many others, often didn't fit neatly into the boxes -- a fine line between who gets help and who goes on without it.
In October 2015, a public defender flagged his case for a mental health screening. A counselor said Adam appeared to "currently suffer from symptoms of a mental disorder."
But the counselor also found he could understand the legal proceedings well enough to assist in his own defense -- so he wasn't flagged for treatment. Instead, Adam was jailed for a month and fined $600.
Adam did try to get help on his own, frequently showing up at local hospitals; medical records document at least a dozen trips to Seattle-area ERs between 2016 and 2022. There are currently no walk-in centers for behavioral health crises in King County, though last spring voters approved a property tax that will build several facilities in the coming years. Meanwhile, ERs have taken the brunt of handling cases like his.
By May 2016, social workers at Swedish Mill Creek Campus noted Adam had been in their ER four other times in the past year, often in need of food and a shower.
Medical records show he told staff he was living in the woods when he wasn't in jail and that others could control his mind.
"I needed to find a place where I could get some help and feel safe because I just feel like I can't live like this anymore," he told a social worker that May.
At times, the records reflect hospital staff's impatience with Adam's visits. He sometimes seemed manipulative and mostly needed food and housing, but they were not a shelter.
Adam would push back. "I want a new doctor!" reads a medical note from the Swedish Edmonds Campus' emergency department in the summer of 2017. "Nobody cares that I am dying."
ADAM FITS INTO a population described as "frequent flyers" or "high utilizers" -- people who cycle in and out of jail and the behavioral health system, often charged with minor crimes and released or sent to treatment programs for a short period before they end up homeless again.
It's a small group -- in Seattle, the city attorney's office keeps a list of 168 people. But they have an outsized impact on behavioral health resources. For years, local governments and health services have struggled to figure out what to do with this group of people. Approaches often ping-pong people between harsh enforcement policies and jail sentences or promote therapeutic programs that can help some individuals but have failed to get the political backing, scale and resources needed to be wholly effective.
While therapeutic courts are popping up to divert people like Adam, many don't qualify for the programs. Sometimes, the person's charges are considered too severe, or they lack the mental competence to agree to the requirements. Even if a person makes it into a diversion program, they often face interconnected challenges, struggling with other needs, such as housing, transportation or employment.
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Adam's longest criminal sentence came in 2017, when he was arrested for possession of a stolen vehicle and possessing a firearm he wasn't allowed to have.
He spent three and half years in prison, mostly at the Monroe Correctional Complex. Finally without access to illicit drugs, Adam could potentially get back on track, his family thought.
Instead, Adam's phone calls to his sister often didn't make sense. He'd talk about a computer or light that was inside him. Even his voice changed, she noted.
During his incarceration, Adam took at least four different psychiatric medications and spent several months in an observation unit, prison medical records show. Mental health professionals at the prison diagnosed him with schizoaffective disorder, a type of severe mental illness accompanied by hallucinations or delusions and depression.
In the summer of 2020, Adam finished his prison sentence, but the cycle continued unchanged: three arrests that year and more than a dozen interactions with law enforcement in Everett, Marysville and Arlington the next year, mainly for minor incidents. In the end, he was released back into homelessness.
That changed in March 2022 when Adam threw a beer can at an Everett police officer. Facing a felony for assault, the charges were finally serious enough for the system to grant him competency restoration treatment at Western State Hospital.
Heidi only found out her son was at a psychiatric facility when she received a Mother's Day card from him. The two reconnected immediately.
"I was excited that maybe somebody was going to get to the bottom of the mental illness and help him," Heidi said.
With consistent medication, Adam finally sounded like himself again, his sister remembers.
"My brother came back 100%. He was back like when we were kids, and I could talk to him, and it was him. He had a sense of humor, and he was sweet and kind and compassionate."
But in early 2023, the family was alerted Adam would be discharged soon. The problem was where he would go next.
Staff members asked Heidi if she would take Adam in. She thought back to other times he stayed with her, their fights and how overwhelming it was. She didn't feel capable; she wanted more help dealing with his drug use and mental illness.
Adam had also burned through other relationships. His great-uncle Carl Pennington acknowledges he cut communication with Adam.
"My theory's always been, if somebody needs help, the thing to do is try to give them the best help you can, without harming yourself," Pennington said. "I was harming myself."
The staff at Western State instead offered Adam a placement at a halfway home. He declined it, fearing his rights would be taken away, according to his sister and mother.
It's common for people with severe mental illness to decline treatment -- this cruel symptom is known as anosognosia, where the brain is unable to recognize itself as sick.
It's part of what makes involuntary treatment a thorny issue among advocates, criminal lawyers and judges, and families. Washington is known for having laws that prioritize patient's rights: Here, only a designated crisis responder can start the process to involuntarily commit someone -- and only if the person in crisis is a threat to themselves or others or gravely disabled, meaning they aren't eating, sleeping or taking care of themselves.
Western State staff determined Adam didn't meet that criteria.
Records obtained by The Seattle Times show the hospital set up Adam to be discharged to 97 S. Main St. -- the Bread of Life Mission, a nonprofit Christian social services agency in Seattle'sPioneer Square neighborhood.
No information was noted for a case manager or mental health treatment. For his crisis information, staff wrote down a 1-800 number for the King County crisis line.
Heidi reached out to Western State staff to say that her son's symptoms seemed to be returning.
"So everyone who has spoken to Adam in the last few weeks has noticed a change in his demeanor. Adam has also started talking about the light ... talking to himself and answering himself. He definitely has something going on," she wrote in an email.
One of Adam's persistent delusions was that he had a light inside of him that could keep him warm or heal other people.
The social worker wrote back: "I appreciate the update, Heidi. Thank you. I will let the psychiatrist know. However, he is still scheduled to discharge to the shelter tomorrow."
The social worker who corresponded with the family did not respond to several requests for comment. Aaron Goddu, the director of community transition for the state hospitals at the Department of Social and Health Services, said discharging a patient into homelessness is "really our last choice."
Goddu added that it's rare, and clinical leadership is aware of those cases and approves the discharge.
"It absolutely has happened, and it can happen," he acknowledged.
A department spokesperson added that while Adam's judgment was poor, he did not meet the criteria for involuntary treatment under Washington's strict laws
Even long-term care services were not an option; Adam was able to functionally care for himself when it came to eating, walking and basic living activities, making him ineligible for more support.
Officials say that a psychologist at Western State also offered him the chance to stay at the hospital voluntarily until they came up with a better housing plan. Adam declined that and any outpatient substance use disorder treatment.
So, Adam was dropped off in downtown Seattle. It's unclear whether he even went inside the shelter. The Bread of Life Mission has no record of Adam ever spending the night.
Shelter staff said a few psychiatric patients are discharged into their care every month. Often, staff don't have a diagnosis or know what to expect.
"This isn't a hospital," said Michael Lloyd, the operations and shelter manager at the mission. "We're limited in our abilities to deal with people like that, but we still try to provide the best situation for them."
IN EARLY FEBRUARY, Heidi drove up to Seattle from Portland and met up with Adam a few days after his discharge.
They got hamburgers together, and that night she got a hotel room and watched as her son talked to himself. She tried to reason with him to come live with her or get some medication. Adam refused.
The next day was the last time Heidi saw her son. She called the crisis line for help, and they told her to take him to the ER.
But "the minute he saw that hospital, he tried to jump out of the car," Heidi said.
So she tried local police. It took hours to hear back, and she ultimately left Adam in the Green Lake neighborhood, at his request, and then drove 170 miles back to Portland.
"I called the two entities who are supposed to help," Heidi said tearfully.
"I don't know what the answer is. But I know that wasn't the answer."
Four weeks later, on March 6, 2023, the family got the dreaded call.
Adam was at Harborview Medical Center. Emergency dispatch records indicate a man matching his description had been found unconscious at Third Avenue and Cedar Street in Belltown. He had overdosed on meth and fentanyl and was considered brain dead. He was also COVID-positive and had multiple rib fractures.
Though the family wanted to donate his organs, they were too damaged. Instead, hospital staff took a handprint and a lock of hair.
For Heidi and Bethany, connecting the dots of Adam's life and death, his lack of care and his constant pinballing between various systems, is part of their grief process.
Heidi wants to see the broader community step up to care about people like her son.
"We need to stop being disgusted by people living on the street; we need to stop being disgusted by the mental illness that happens; we need to stop looking the other way when somebody looks different to us," she said.
"And we need to start figuring out an answer."
Mental health resources from The Seattle Times
* Mental-health resources in King County and Washington state
* Where to find diverse mental health resources in Seattle
* Here are the basic facts about mental health and treatment in Washington state
* Seattle youth guide to multicultural mental health resources
* What you need to know about mental health and schools
* Mental health resources for young people
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