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This message comes from NPR sponsor Shopify, the global commerce platform that helps you sell and show up exactly the way you want to. Customize your online store to your style. Sign up for a $1 per month trial period at shopify.com slash NPR. Lost Patience is about serious mental illness. This episode includes details about drug use and mentions suicide, so it might be disturbing for some listeners.

When you're dreaming, you know you'll see things that are fantastical. Obviously, none of it is really happening. But when you're in a dream, you don't know that. When you wake up from a dream, you realize, oh, that wasn't real. But when you're in a dream, it's totally real. You have no idea that it's not actually your life. When I've had chances to ask people what psychosis is like, more than one has answered like this, that it's kind of like a dream.

Psychosis is what we call it when someone loses touch with reality, usually because of a serious mental illness like schizophrenia. What I've learned is that psychosis can be wonderful in the ways dreams are wonderful.

It's euphoric in some way.

I think I felt sort of euphoric at the same time I was feeling fright. And psychosis can be terrifying in the ways dreams are terrifying. I would be looking at somebody and I'd see their face and I'd turn around and it wasn't that same person. It was like they had a different face. I had an episode thinking I was going to be poisoned and I wouldn't...

I think that these people are chasing me and I'm hiding and I'm crying. It was like living a total nightmare, like a sci-fi nightmare. There's a reason I've tracked down people who can explain what psychosis feels like on the inside. It's because like a lot of us living in a city in the U.S. today, I see psychosis all the time from the outside into us on the outside.

Psychosis often looks like this. Police officers in my city, Seattle, responded to almost 10,000 scenes like this last year. Scenes of people who seem to be having a crisis.

Mental illness can cause a bunch of different symptoms, and psychosis is only one of them. But psychosis is often what's happening when we see someone in these moments of crisis, their inner dream spilling into the outside world. Here in Washington state, a state report found 7% of adults have a serious mental illness, the second highest rate in the country after Alabama.

And over the past decade or so, I've watched Seattle become one of a handful of cities gaining attention as national symbols of a mental illness catastrophe on our streets, adding to a feeling that U.S. cities have fallen into chaos and decay.

that something in our society has gone deeply, almost spiritually off course. I want to talk to you about a crisis we see all around. I think this decade will be known as the decade of the behavioral health crisis. There is no issue that I hear about more as a council member. There is no issue that keeps me up at night more consistently. This is California's original sin.

I mean, this is the manifestation, isn't it, of our failure. All around the U.S. right now, mayors, governors, lawmakers are scrambling to add hospital beds and pass laws making it easier to institutionalize people, reviving debates older than this country about when and how we should intervene when someone's so sick they don't know they're sick. Untreated psychosis can be a cruel disease.

But the reality remains. Many people with serious mental illness cycle between hospitals, jails, and the streets, ricocheting from one desperate situation to the next.

year after year. There is not a single behavioral health walk-in care facility in King County. Why does it feel like these issues are reaching a breaking point lately? As a reporter covering homelessness and other social issues here on the West Coast, I've had a question. A lot of questions, actually, but they boil down to one. Why is it like this? Why are people who are so visibly, obviously mentally ill just out here?

My colleagues and I at KUOW and The Seattle Times have spent months looking into this question. It's led us inside homeless shelters and jails, hospitals, courtrooms, inside families' homes at moments when it felt like their lives were unraveling. It's led us into an abandoned psychiatric hospital and more than a century into our country's past.

And we have answers. We think we can tell you what happened to psychiatric care in this country, why so many people who need this care the most end up lost. I'm Will James from KUOW and The Seattle Times. This is Lost Patients, Episode 1, Churn. What you're about to hear is from a video shot in a Seattle hotel room about a year ago in February 2023.

You do it every fucking way, but it doesn't show that you're not fucking walking. You're caring about every bit of it. Who are you talking to? Is it all right? In this video, Adam Orant sits on a hotel bed, still bundled up like he's outside in the Seattle winter, in a puffy blue coat and gray beanie. He talks to an empty space in front of him and a little to his left, leaning forward, his face scrunching in concentration.

His mom, Heidi Arendt, is reflected in a mirror behind him, filming with her smartphone, watching her 40-year-old son. Heidi's not sure what to do except to create a record of this moment. She wants a record of the fact that her son is not doing well. What? What's all right? Are you just talking? Oh, okay.

Washington State's largest psychiatric hospital has just released Adam and had him dropped off at a homeless shelter in downtown Seattle. Heidi has driven hours from her home in Portland, Oregon to try to save him before he drifts away again. It's part of a pattern Heidi has witnessed for about eight years as Adam has bounced between emergency rooms, psychiatric hospitals, jails, prison, homelessness, and has been in a lot of trouble.

And now it's happened again. Another institution that was supposed to help Adam has spit him out back onto the streets, even though Heidi, watching him in this hotel room, can see he's not okay. That night, Heidi can't sleep, so she stays up talking on the phone with her daughter, Adam's sister, Bethany Anderson. They come across an article online by a Seattle Times reporter named Esme Jimenez, who writes about mental health, and who has just published a story about the hospital that released Adam.

Not long after that, Heidi and Bethany reach out to Esme to see if she can help figure out why this happened. I received an email from his sister and mother. And so then I was like, OK, I got to figure out what happened then. What happened? And then I was also curious, like, why can't he get better?

Like if his mom and sister are trying, if he's gone to hospitals, if he's gone to jails, shouldn't one of these things have worked? As a reporter covering mental health, Esme had dug into the question of why people like Adam move through a maze of institutions and often end up right back where they started. Esme had heard all the euphemisms that cops, prosecutors, nurses, and social workers use for people like Adam.

There's friendly faces. That's the language that really kind social workers will use for the frequent flyers, which is the less kind word. Then there's familiar faces for how often they return to jail.

No one knows exactly how many people get caught in this loop, but a decade ago, policymakers in the Seattle area gave a rough tally of more than 1,300 people at the time. They counted those who had gone to jail more than four times in a single year and found almost every single one of them had a mental health diagnosis, a substance use problem, or both.

For Esme, Adam's life provided a roadmap of how someone ends up in that loop. It was almost like I read the end chapter of a book and I was like, that doesn't make any sense though. So I need to go read as far back as I can to make sense of how we ended up here. As a kid, like six, seven years old, he'd go get lawnmowers that adults had given up on, put them back together and they'd run. Adam Arendt wanted to fix things.

At Heidi's house in Portland on the mantle, she has a photo of Adam as a grinning little kid lying underneath a tricycle that's propped up like he's a mechanic working under a car. That is Adam. He was two years old and he was working, or he was probably three. He was working on his big wheel. He was going to fix it.

Adam's little sister, Bethany, remembers him accumulating a junkyard of broken toys in their yard in small-town Georgia. My brother would go get power wheels that other kids had thrown out or whatever. He was going to fix them. He was going to fix them all for me so I could have a power wheel. And when they didn't run, he would push me in them. Adam had a leg that turned out 180 degrees at that point. That was before surgery. And he was in a lot of pain.

And he literally had a hard time moving. And he was in that backyard just pushing her all over as if it just was nothing to him. It was just, yeah, he doted on her. Heidi says some of Adam's knack for fixing things came from his dad, who taught him how machines work. But Adam inherited something else, too. His father's brittle bone disease.

Adam spent his childhood in a body that broke easily. We let him ride bikes, and a kid went in front of him, and he went over the handlebars, and he broke his hip, his pelvis, his arm, his wrist, his face. There's a picture over there of him walking with his cane. He had a walker for a while. He had a hard childhood.

He had a hard life. Adam's parents split up when he was young. Heidi eventually settled in Portland with her three kids. Along the way, Adam held them together. He was quiet, grounded. He was the middle child, and he was the glue. Adam made money doing body work on cars. The way his mom and sister talk about him, it's almost supernatural how good he was at anything that required patience and precision.

There's a video of Adam and his older brother Jason jamming on instruments at Seattle's Pop Culture Museum. Adam's on guitar. He could pick up something and he could learn how to fix it or learn how to play it or learn how to train it or whatever. And he had the patience of a saint. Adam could train a dog without treats, without harsh words. He just was one with the dog. And he didn't even say, come.

He just made a noise, and the dog was right to decide. On one of the Facebooks, it has a picture of a car Adam redid. It was rusted out. It was not running. It had no engine, nothing. And he redid the entire car. I mean, from the bottom to the top, it was cherry-coated, painted. It was meticulously done, and he had such finesse with his hands. He took pride in everything. So to see him go from that...

to this downward spiral. Something changed when Adam was in his 20s. His mom and sister say it started around the time a girlfriend left him. At first, it just seemed like a heartbroken young guy withdrawing from his family. Years later, they'd learn a man in his 20s withdrawing from his family is also a pretty classic sign of the onset of schizophrenia. At their house in Portland, Heidi found a spoon Adam was using to cook heroin in his room.

Heidi blames Adam's opioid use on all the pain medication he was prescribed as a kid for all those broken bones and surgeries. Then Adam started saying and doing things that scared his family. 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.

And I remember Jason and I, we both pulled up and we were like, what's going on? There was no one there. He did get violent one night with an axe where he was sure there was somebody in here. I had a couch here and he was hitting it with the axe. And I'm a wimp. You start violence around me and I'm a wimp. So my son took him in.

While Adam lived with his older brother, Jason, he started complaining that a metal plate a surgeon had put in his leg long ago was hurting him, and he was going to cut it out himself with a knife. He didn't seem to remember a surgeon had already taken out the plate years earlier. Heidi called 911, hoping to send emergency medical technicians over. Instead, she got police officers with guns drawn in her son's yard. I said, he's not violent. He's hurting himself.

And in the house was my grandson. They were right outside of his window. Jason, of course, didn't take it very lightly. You know, told him they better drop their weapons now. But yeah, it was scary. Heidi and Bethany say for a long time, everyone blamed Adam's behavior on drugs.

It would be years before doctors would diagnose Adam with schizophrenia, schizoaffective disorder, bipolar disorder, other mental illnesses. It would be even more years before his family would find out about any of these diagnoses. So back when Adam started worrying his family in his 20s, Heidi did not immediately think of her own father, Adam's grandfather.

I learned from your conversation with Esme that your dad, your dad had schizophrenia? Yes. Did you know him well? Like, do you remember what that was like? I didn't know him well. We didn't live with him, but he did have one break while I was around him. I was probably about seven. I had gone to visit my grandma, and my dad was there. And all of a sudden, he wigged out totally.

And he had my grandmother with a telephone cord around her neck choking her. And I went running to neighbors who didn't open the door. And that was the last time I saw my dad until I was a teenager. Adam's grandfather's schizophrenia may be a clue, but it's not the whole story. For about a century, scientists fought over what causes serious mental illnesses like schizophrenia. And here's where they've landed.

The formula is basically some genes you inherit plus something that happens in your life to unlock them. But exactly how these two factors work together is still a mystery. The genetic part, it's not just one gene you can easily test for. It could be thousands of genes all working together in ways we don't understand that add up to a risk of one of these disorders.

As for the factors that can unlock a psychotic disorder in someone, we don't fully understand those either. Trauma, stress, and certain drugs seem to play a role. Research shows something about being poor, being a new immigrant to the U.S., or just being born in an urban environment makes a psychotic disorder more likely. What is clear is that serious mental illness is not just something we're born with.

It also has to do with the world we're born into. There are going to be people with a similar level of genetic risk, and one of them is developing the illness and one is not. So you can't deny the importance of psychosocial factors. Katherine Jonas grew up here in the Seattle area and now researches psychosis at Stony Brook University in New York.

She spends a lot of time on the genetics side of things. But what she means by psychosocial factors is the spooky way our genes interact with events in our lives and the societies we live in to bring about diseases like schizophrenia. In non-Western countries, outcomes in schizophrenia tend to be much better.

People tend to recover more commonly. And there's no evidence that that's a function of genetics or ancestry at all. So I think we have to infer that these are probably social processes. And that's where you end up, you know, maybe as like a researcher, a psychiatrist, it feels a little scary.

Chris Hudson spent decades as a professor at Salem State University in Massachusetts, studying how society handles serious mental illness.

But before that, Chris was a social worker, and he used to collect what are called social histories of patients at a psychiatric hospital. That meant getting them to tell the stories of how they got sick. And a lot of those stories had something in common, an event that seemed to set off their disorder. There was often a death.

or rejection, or really traumatic loss, either a parent disappearing, a parent dying, or maybe a girlfriend or boyfriend rejecting them. It could have been any of those things. What was for them a traumatic loss? Adam's family didn't know any of this. But looking back, there were signs he had both a genetic risk for a psychotic disorder and by his 20s, enough trauma in his young life to possibly unlock it.

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What's happening on NPR Podcasts? More neighborhoods and more perspectives. The more of the world that you hear, the more you hear the world as it really is. NPR Podcasts. More voices. All ears. Find NPR wherever you get your podcasts. This story is about what happens when two things meet. Serious mental illness and the infrastructure we've built to respond to it.

But to understand the second half of that equation, what we've built and where it goes wrong, you've got to understand the illness. When someone's brain gets sick or injured, the boundary between what's real and what's not can get blurry. Doctors call this blurry state psychosis. All sorts of things can cause it: a stroke, a head injury, a high fever, or a reaction to a medication.

But most of the time, it's a serious mental illness like schizophrenia or severe bipolar disorder. There's currently no blood test for psychosis, so to diagnose it, doctors look for a few telltale signs: disorganization, hallucination, and delusion, all of which we'll get into. It's worth saying though, plenty of people who experience psychosis come out of it and have careers, relationships, families,

These are the people we've turned to as guides because they've walked some of the same roads as Adam. For a lot of them, psychosis started out slow and insidious.

I went from being a really prolific artist and playing guitar all the time to literally just sitting on the couch for hours. And I remember I would just sit there and I would think to myself, get up and do something. Do anything. Do anything at all. Get up and eat a meal. Do something. And it was like I was locked. Carolyn Ponzoa's first full-blown psychotic episode started when she was in college in Wyoming. She stopped going to class, stopped socializing, lost interest in her hobbies, and

She'd later learn that the first phase of psychosis can look a lot like depression, as if your connection to the real world is fading away. There'd be this disconnect from reality where even though I was present in reality and I knew what was real, I had sort of like a filter between me and the world where it was almost like looking through a film. Like I'd look at the beautiful landscape at school in Wyoming and think,

Why do I feel so detached from this? Why is it like I can't touch this? Why is it right in front of me and I feel so disconnected from it? And those thoughts would just be, I think, looking back, the first indication that it was starting. Carolyn left college and moved into an apartment close to her mom here in Washington state. And it was here that this feeling of disconnection grew fully into psychosis, a rupture with reality.

It was the first of several episodes Carolyn would experience. She's since gotten a diagnosis of schizoaffective disorder, basically schizophrenia plus bipolar disorder. Carolyn says when her psychosis is ramping up, she or the people around her can sometimes notice her thinking change. She says her thoughts leap from one idea to the next, making abstract connections other people can't follow, finding meaning and symbols in things other people don't.

Here's an example of what her thoughts were like during one of her stays at a psychiatric hospital.

They would just be totally abstract, like, oh, that guy's playing basketball. Okay, so he's in charge of the sun because the basketball is the sun and I'm in charge of the moon. So I'm just going to flicker this light on and off and that'll change from day to night. My mind is working really fast and piecing together these symbols and making sense of them in its own strange way. And, you know, I thought I was changing day and night rapidly. And someone said, you have to stop doing that. People are trying to sleep.

This is one common sign of psychosis: disorganization. To us on the outside, it can look like someone talking fast, getting lost in tangents, or even just stringing seemingly random words together. A second sign of psychosis is hallucination: hearing or seeing things that aren't real. Back in 1989, Lew Middleton was in his 30s, working at a warehouse and living in a basement apartment in the heart of Seattle.

Blue was listening to a lot of 80s metal and dance music at the time and played albums through speakers in his apartment. But one day, he noticed what sounded like voices mumbling in the background. I would turn on a song and a person would say, uh-huh.

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. I liked Annie 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, so if you're hearing my voice...

That means you're part of this movement that knows that there's something going on and that there's some changes that are going to take place. So be very careful. You'll get more information along the way. And then it would go away. And then I would put on another album and then that singer would say the same thing. And I'm going like, how am I getting this? How is this? I want to say here, Lou wasn't hearing these voices in his head, like his internal monologue.

To Lou, the voices were coming in through his ears, from outside of him. And as Lou got more stressed, he says, the voices came to him not just in music, but in any kind of constant or rhythmic noise. Buzzes or hums of appliances or machinery. They'd say they were after him. He started to believe them. I was just completely consumed by

Every movement, everything I was doing was because of the voices. The idea that people were chasing Lou became his reality. He ended up fleeing into the woods and living out there for a while. After disorganization and hallucination, this is a third sign of psychosis. Delusion. Believing things that aren't real. As I talk to people who have been through psychosis, it stands out how similar a lot of these delusions are.

the same basic stories repeat over and over again. They're being stopped or chased by a stealthy power, maybe the FBI, or they themselves are God or Jesus, or someone close to them has been replaced by a person who looks exactly like them but isn't them. Of all the things someone's imagination could conjure up, why these particular things? There's no conclusive research I could find on this,

But some experts explain it like this. A feeling comes first, like paranoia or grandiosity, and then a story sprouts from that emotion. The feeling of paranoia becomes the FBI is stalking me.

grandiosity becomes, I am God, or I control the weather. So there's the core thrust of the delusion. And then there are the specifics about how it happens. Catherine, the psychosis researcher, says those specifics have changed as our societies have evolved. A long time ago, delusions were mostly about religion or magic.

Then they got more political, and later, more about technology. When radios were first developed, that worry that there was a radio transistor somewhere in your body became really prominent. And in the era of reality television, there was the onset of what people were calling the Truman Show delusion, believing that you were the main character in some sort of

reality TV show in there where camera's following you and recording your... Oh, and everyone's an actor. Right. Everyone around you is an actor. Right, right, right. Adam Arendt also had a particular delusion. Esme of the Seattle Times saw it over and over again in Adam's medical and legal records. Adam believed he had a light inside of him.

Adam thought that he had a light in him that could heal other people. I know this because he's told prison staff, he told medical staff outside of prison, and he told his mother that and his sister that.

His mom said there was one time where an aunt was sick and Adam said something under his breath to her like, yeah, I tried doing what I could, but, you know, couldn't do enough. And she was giving me these comments because she was looking in retrospect, being like there was all these little instances that now she's able to kind of name of times that he was having some kind of delusion. What's important to understand about psychosis is a particular reason it's unlike any other medical condition that

It's that psychosis can feel so real, so all-encompassing, that the person experiencing it doesn't believe they're ill. There's a word for this, anosognosia. It comes from ancient Greek, disease without knowledge. The part of you that's supposed to recognize you're sick, the brain, is the part that is sick.

Anastomosis is what makes psychosis not just a private medical problem, but also a social puzzle. It forces the rest of us to decide, at what point do we step in? Everyone I've talked to who's been through psychosis had a moment when their dreams spilled out of their private world and into the real one.

They ran through town naked or walked fully clothed into a lake. They told police that their workplace was about to be bombed or that they just murdered their husband when in fact their husband was actually fine. A person's entire life can depend on how the world reacts in these moments. A police officer sees you as someone who needs help or someone who's a threat. They decide to book you in jail or take you to an emergency room.

The psychiatric hospital happens to have a bed for you that day, or it doesn't. If you're lucky, this can go right. Or, as in Adam's case, it can show just how wrong things can go.

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There's a spot in downtown Seattle where, if you look around, you can see our modern psychiatric system laid out around you. A nexus of homeless shelters, hospitals, and the criminal justice system. Esme and I met up there one day to retrace some of Adam's steps. For people who have serious mental illness, how many different buildings around this spot would they potentially touch?

Everything from the Morrison Shelter on our left, this brick building, the courthouse across the street, the jail, which is a little bit further up. There's another shelter over there. And people hang out here at Pioneer Square Station. What do you call that phenomenon of people with severe mental illness just sort of bouncing from place to place to place for year after year after year? Like, do you have a shorthand for that phenomenon?

I think I've called it the churn because it feels like just this cycle where people repeat the same thing over and over. I've heard the revolving door, a maze or a labyrinth, ping-ponging through different systems. I like the churn. The churn is an apt but sad one. It reminds me of waves bringing you back to shore again and again and again and again. The churn.

This is how Adam spent about eight years of his life. When you churn in and out of institutions for that long, your life plays out on paper. Every one of these buildings you walk into, there's a record, a report with your name on it.

As Esme charted Adam's journey, a mass of these documents filled up her laptop. I was just flooded with these little puzzle pieces of this man, seeing, okay, he was here at one point, then he travels over here. Somehow he ends up in this other county. So just kind of trying to, like, follow his tracks. Adam's churn started around 2015, a few years after Heidi and Bethany started noticing changes in him. He had been bouncing around with different family members, including a great-uncle here in Seattle.

First, Adam starts popping up in police reports. Driving without a license, not paying transit fare, criminal trespass, assault. But all these misdemeanors are too minor for Adam to get a mental health evaluation. Esme says there's such a huge backlog of people waiting in jails to get evaluated in a psychiatric hospital, the amount of time Adam would have to wait is longer than his sentence would be if he's convicted. So prosecutors let him go.

In 2015, Adam gets treatment at a methadone clinic for about a month to get his addiction to opioids under control, but it doesn't work. Heidi says Adam started injecting the methadone to get high. Then in 2016, about a year into Adam's churn, his great-uncle cuts ties with him, and Adam loses the camper he's living in on his great-uncle's property.

Adam ends up homeless. And homelessness makes everything worse. He starts showing up in emergency rooms, looking for help. This is 2016, and the social worker notes, patient has four emergency department visits in the past 12 months. He reports that he is homeless and came to the emergency department for help for his suicidal ideation and depression. Patient states this to the writer, I have been feeling like this on and off for a couple of months. I'm so stressed out with my current situation.

I felt that 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. 2016 is the year Adam overdoses for the first time. For years, the people around Adam had tried to parse whether drugs or mental illness is at the root of his problems. So it's worth spending some time talking about how hard it is to draw a clear line between those two things.

With almost every person I've talked to who's had psychosis, drugs were part of their story at some point. But mental illness and drugs were braided together in ways that blurred which was the cause and which was the effect. That's how it was for Carolyn, the person who thought she could change daytime to night. It's definitely...

It's definitely like one of those questions of what started first, the addiction or the psychosis, because they started around the same time. And I learned that I do have schizoaffective disorder, but it can be triggered by marijuana, for instance. So I would keep using it to self-medicate because I just didn't want to feel anything and I wanted to be numb to my emotions.

And then I would just slip into psychosis. And it was this constant game of in and out of psychosis, in and out of sobriety. And pretty much every time I'd pick up marijuana, I'd go right back into psychosis. And I just couldn't stop. Research shows cannabis, and possibly other drugs like meth, may act like triggers for psychotic disorders in people with a genetic risk, like Carolyn.

Yes, cannabis, a drug that's legal in most states and safe for many people, pops up eerily often in the stories of psychotic disorders. Studies show someone who uses weed heavily in their teens is more likely to have a psychotic disorder as an adult. But it's not so simple, because psychotic disorders often start quietly in someone's teens before the signs are visible to anyone else.

So what if the weed use isn't a cause, but an effect of a psychotic disorder quietly awakening in someone? That's what makes this hard. The drugs that may trigger or worsen psychotic disorders are some of the same drugs people use to try to medicate their psychotic disorders.

Researchers continue to debate, are certain drugs causing psychotic disorders? Are psychotic disorders driving people to use drugs? Or does some third factor, poverty, isolation, trauma, make someone susceptible to both things?

What's clear is that once mental illness and drug use are braided together, treating either one becomes much more complicated. As soon as you help them, say, get on an antipsychotic so their schizophrenia is stabilized, that's when the other monster, like this hydra, rears its head and suddenly it's the substance use that you have to go after. And maybe you finally get the substance use down, you know, you get them to a methadone clinic, you're getting them on a path to recovery when their mental illness starts destabilizing again. Yeah.

In 2017, two years into the churn, Adam ends up in emergency rooms ten times. At one point, he shows up covered in feces and tells the staff he had a delusion about a lizard inside his body. Staff at the hospital flag Adam as someone who may need to be detained for psychiatric treatment against his will, but it's not clear that happens.

And if it does, it doesn't last long. A couple months later, Adam overdoses, ends up at an emergency room, gets released, and police bring him back to the emergency room the next day. Quote, the patient was breaking things at McDonald's. Law enforcement states that he said he wanted to kill everyone. His labs at the time showed that he is positive for meth. Ultimately, he declines mental health resources or drug treatment, and they discharge him with a bus ticket headed north. Just north? Yeah.

That's what it says. At one point, Adam shows up in an emergency room with what's described in a report as altered mental status. Adam tells staff he used heroin that day. And when they ask why he's there, he starts crying.

His mom, Heidi, has highlighted a line from this report. You can see the first time that she highlights a doctor saying, Adam has a strange affect. I'm wondering if he has schizophrenia. That means he's talking a little bit flat or a little bit different. But that doctor's observation about possible schizophrenia, it goes nowhere. Sometimes a doctor would give Adam a diagnosis, then Adam would show up somewhere else, and a different doctor with none of that information would start over from scratch —

Diagnosing mental illness is more of an art than a science. Doctors make judgments based on what a patient is willing or able to share and what the doctor observes in front of them for however long they're with the patient.

Over the years, different doctors attach different names to what's going on with Adam. They call it everything from schizoaffective disorder. He also gets just schizophrenia. He gets just bipolar disorder. He gets obsessive compulsive disorder, substance use disorder, depression period, anxiety period. What do you make of that? That among the people that are the most ill, it's really hard to narrow down exactly what's going on with them.

What this also tells me is that Adam was severely sick and people were not sure exactly what to name it, but there was something going on. Adam is detained in psychiatric hospitals a handful of times, but it's not clear if doctors prescribe him antipsychotic medication. His family hasn't had access to those records. As Adam floats in and out of all these different institutions, there's a disjointedness to everything.

no one ever seems to spend enough time with him to really get a handle on what's going on. The staff only see him for 24 hours or six hours, however long they have him for. Police will have him for four to 12 hours. A judge might see him for 10 minutes to 40 minutes. Like, no one stays with him. The whole time, Adam's family works the phones, trying to keep track of him. My mom and I go through periods where we would ask each other, it'd be a month, two months, do you hear from Adam? No, I haven't heard from him.

That changes in 2017, when Adam is finally convicted of his first felony for stealing a car.

His prison sentence is three years. And for Heidi and Bethany, this is a relief. They were thinking, well, he's surely got to dry out now, right? He's in prison. Sure, maybe they have access to some drugs, but like he'll stabilize. And what they realized is that he was not stable. I went up there and he told me he was gone.

We talked about the little man inside him with the computer, and he'd fix everything, and I didn't need to worry about anything. And that was a constant talk that never ended about the computer in him, the light in him, and he was able to fix it all. I went to go visit him in 2019. At that point, my brother had been in prison for at least a year, if not two. We should have seen...

right? But we're sitting at this table and his behavior was erratic. And he was like side whispering to himself. A report by the prison records Adam's side of what was going on in that room. Patient reported his sister visited for an hour. Patient shared that toward the end of the visit, patient believed entities were threatening her, which he shared with his sister. Patient shared that his sister consequentially became freaked out and left. It got to the point to where

This was 2019, four years into Adam's churn.

And it was suddenly clear that after Adam's dozens of arrests, emergency room visits, and hospitalizations, after all the people in all those institutions had spent incalculable time and money on Adam, none of it had made him better. In fact, he was worse than his mom or sister had ever seen him. The most consequential decision of Adam's life, that's still to come.

That decision will bring us back to Heidi recording Adam in that hotel room after he'd been released from Washington's largest psychiatric hospital and what unfolded next. For Esme, following Adam's story would unlock a fundamental truth about psychiatric care in the U.S. I think I did start with being like, oh, it's a broken mental health system. What gaps would fill the needs here? And then I think through Adam, I was like, that was such an innocent idea, right?

But to get to that point, the point of clearly seeing the problem, we have to look closely at the maze people like Adam and their families are lost inside. I've come to imagine it as a giant house where a different architect has designed each room, and none of the architects have talked with each other. Imagine what a house like that would look like. There's no lights in the hallway, you might say. Well, that wasn't my job, each architect says. My job was to design this one room.

There aren't any stairs, you might say. Well, that wasn't my job, each architect says. There are five bedrooms, but no bathrooms, you might say. Well, that wasn't my job, each architect says. Over the next five episodes, we're going to tell you the story of this house. Who built it, how it got built that way, and why it's stayed that way. And only then can we really make sense of what happened to Adam.

Coming up on Lost Patients, we're going to look at one part of that house, the front door, and why it's so hard to get people through it at all into psychiatric care. Lost Patients is a production of KUOW Public Radio and The Seattle Times in partnership with the NPR Network. You can support Lost Patients by investing in the local newsrooms and the specialized beats that make this sort of storytelling possible.

Please consider joining and subscribing at KUOW.org and SeattleTimes.com. This episode was reported, written, and produced by Esme Jimenez, Sydney Brownstone, and me, Will James. Our editor is Liz Jones. Additional editing by Diana Samuels, Jonathan Martin, Brendan Sweeney, and Marshall Eisen. Project development by Laura Grenias.

Our music is by B.C. Campbell. Mixing and sound design by Hans Twight. Logo and branding by Alicia Villa and Michaela Giannotti-Boyle. Thank you to Heidi Urand, Bethany Anderson, Carolyn Ponzoa, Lou Middleton, Catherine Jonas, and Chris Hudson for sharing your stories and your expertise.

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