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Before Washington was even a state, it was already constructing its first hospital to house patients with mental illness.
In the 132 years since, there’s been a lot of trial and error but no clear answers as the state — and the country at large — have grappled with their approach to mental health care.
Along the way, how we think about mental health as a society has also shifted. Mental illness that was regarded as a personal fault is now being understood through several lenses. Researchers and providers are exploring the impact of trauma on the body and how genetics play a part. Psychologists now examine the sum of complex systemic issues like poverty and racism when thinking through a person’s mental health.
Still, challenges have persisted for individuals with severe mental illnesses, their families, and communities. An estimated 1 in 5 residents in Washington currently lives with mental illness, and the state has long struggled with funding the care of the most severely ill patients at state psychiatric hospitals. Many people have landed in jail or prison while unable to find adequate care; others have landed on the street. In a 2020 survey documenting homelessness in King County, more than half the respondents self-reported they’ve dealt with conditions like depression or schizophrenia.
So how did Washington state get here?
To better understand we must look to the past, the choices made by our predecessors, and how that’s carved our current mental health landscape.
The region’s first patient
Edward Moore, a 32-year-old sailor, is one of the first documented cases of a resident with mental illness in the Seattle area in 1854. (Josephine Ensign, a professor at the University of Washington, documents Moore’s story and others in “Skid Road: On the Frontier of Health and Homelessness in an American City,” a book about homelessness in the region.)
Moore was found alone on a beach north of the city, in poor physical and mental condition. A doctor started caring for him and asked the territory’s Legislature to pay, but they rejected the request and the high cost for Moore’s care eventually fell on the townspeople of Seattle. They collected funds but that money was ultimately used to send him away on a ship back to Massachusetts, where he was from. Moore died by suicide a few years later.
By 1870, the territory purchased Fort Steilacoom from the federal government and it became “The Insane Asylum of Washington Territory,” housing 21 patients. The facility eventually became Western State Hospital, which still operates today.
Male patients at asylums typically were given jobs like farm work or making shoes or furniture, while women sewed clothes like aprons and shirts.
“We’re giving people purposeful work that is in line with what we as a society believe is sort of appropriate work for them, you know ‘distracting the mind’,” explains Jennifer Bazar, an expert in the history of psychology from the University of Akron.
“On another hand, it’s a great way for institutions to save some financial burdens, when you aren’t paying the staff,” Bazar added.
As the number of patients continued to rise, construction of new institutions followed. Eastern State Hospital near Spokane went up in 1891 and Northern State Mental Hospital in Sedro-Woolley followed in 1909.
New approaches
During this period there were few protections for patients when it came to involuntary treatment. Husbands could send their wives away if they wanted a divorce but couldn’t find a way to do so discreetly. Families who were fighting over property or a business could have that family member committed. Any behaviors that were deemed out of the norm like promiscuity or homosexuality could be reason enough to institutionalize someone.
Asylums were also segregated by race and there were reports of patient abuse and poor conditions. In 1922, Gov. Louis Hart gave a committee the task of investigating brutality complaints. In one case, hospital staffers admitted giving laxatives to patients as disciplinary measures and robbing the patients of food, clothing, and money.
Research at the time was also unable to distinguish between physical disabilities, mental and behavioral illnesses, substance use issues, and more general diseases. Bazar, for example, cites the symptoms of late stage syphilis, or what was then understood as “general paralysis of the insane.” Patients would come in with limited motor abilities and depression as the bacteria that causes syphilis damaged their organs, including the brain.
Eventually, doctors “realized that by raising a person’s body temperature high enough, they could kill the bacteria that was going to cause the damage within the body,” said Bazar. Besides this form of “fever therapy,” doctors continued using occupational therapy and new treatments like hydrotherapy (hot and cold showers and baths), electroconvulsive or shock therapy, and later surgical measures like the now-infamous lobotomy.
At this time, the U.S., like many Western nations, was investing in the creation of national public systems and standards for the likes of hospitals, schools and correctional systems. Research into mental health care was further sparked by “shellshocked” American soldiers coming back from war with symptoms that would now be classified under post-traumatic stress disorder.
This pushed President Harry Truman to sign the National Mental Health Act of 1946, creating funding for the National Institute of Mental Health to study psychiatric and behavioral disorders. Still, issues like crowding and poor funding led to the loss of national accreditation for Washington state hospitals in 1947; it would take almost two decades to get that accreditation back.
By the mid-1950s, Northern State hospital had 2,050 patients, Western State had 3,091, and Eastern State had 2,200. Nationally, the U.S. started seeing a shift toward patient rights. It also coincided with the discovery of antipsychotic medication that was allowing some people with schizophrenia the ability to leave institutionalized care and reintegrate into society. Though more people were starting to voluntarily enter state hospital care, the movement against institutionalization had already begun.
In 1963, President John F. Kennedy, whose sister Rosemary underwent a lobotomy and was institutionalized, launched the Community Mental Health Act, marking the start of deinstitutionalization. The act aimed to release patients from large state mental hospitals into community-based care, a local system allowing people to receive treatment while living near their families and friends.
Alternatives to commitment
“The promise of that was never fulfilled,” said Joe Martin, a retired social worker who spent 30 years serving low-income residents in Seattle and was present for the start of the Pike Place Medical Clinic and the Seattle Mental Health Institute (now known as the nonprofit Sound, the largest provider of behavioral health services in King County).
Indeed, the funding needed to support community-based services was not enough, and the administrations after JFK had different goals and priorities. President Richard Nixon specifically was rebalancing federal budgets after a costly war. The administration also shifted funding responsibility from the federal government back to the states.
Homelessness and incarceration often resulted when people left state hospitals with mental illness, but without homes or family support, let alone work experience or medication. The war on drugs and President Ronald Reagan’s “tough on crime” approach in the ‘80s also resulted in many people with mental illness being jailed for low-level crimes. While Martin was used to serving clients who were low income, elderly or transient, the people coming to him now were distinctly showing outward signs of mental illness.
“In fact, some of the Skid Road guys noticed this new crop of individuals showing up in the community on First Avenue and throughout downtown. They were different.” Martin believes they were coming from Northern State hospital, which closed around 1973 due to a lack of funding.
“It was the Vietnam era,” said local lawyer Richard Emery, who advocated for patient rights. “There was a sense of change, that the law should move forward and recognize issues. And one of those major issues, along with prisoners rights, was closing big mental institutions where there was an awful lot of warehousing going on.”
In the ‘70s, Emery brought a case against the state for the treatment of people in prison with mental illness.
That case eventually led to the creation of the Involuntary Treatment Act in Washington, setting the bar higher for when patients could be involuntarily committed to a mental health facility. Now, a person can only be committed if they are determined to be a danger to himself or others, or have a grave disability that prevents them from caring for their basic needs.
“It was very hard to commit people after that,” said Emery. “[It was] radically new. Way ahead of other states as far as I know, way ahead of New York, California.”
Shifting viewpoints
Today, the pandemic has widened cracks in a strained and tangled system that overlaps between local and federal agencies, and tries to serve thousands of patients.
Many of the issues faced today feel similar to those faced decades ago: the delicate balance between the civil rights of patients versus the responsibility to care for people with severe mental illness; the way forward in terms of treatment; and funding, of course remains a continuing problem. But there have also been major shifts in the state’s approach to mental health care.
Parity laws passed in 2008 now require insurers to cover mental health and substance use disorders just as they would cover other physical conditions. A class-action lawsuit and subsequent settlement known as Trueblood established new timelines for people incarcerated in the state to receive mental health evaluations, rather than wait in jail or prisons for services. Washington is increasingly moving toward alternatives to criminal sentencing, including assigning people to treatment instead. A renewed interest in the use of psychedelics to treat a number of disorders is back.
Some local mental health groups and advocates are excited for the creation of 988, a new hotline expected to launch nationwide next year as an alternative to traditional emergency services that send police to behavioral health crises.
“These last few years, I think there’s been much more focus on behavioral health,” said state Rep. Tina Orwall, D-Des Moines, reflecting on all the changes.
“We’re in a period of time where you say, ‘How are you?’ [and] people don’t say fine anymore. People say, ‘I’m stressed. I’m overwhelmed.’”
Orwall, formerly a social worker, says a positive side-effect of the COVID-19 pandemic is that it has made people more willing to talk about mental health and well-being. When she started at an internship in 1989, the Legislature had just passed SB 5400, known as the Mental Health Reform Act, to continue steps toward community care by establishing local treatment centers and clinics. In many ways, Washington state is still grappling with how to complete that vision.
But she remains optimistic. Over the last few decades there has been a substantial shift in how politicians and the public think about mental health, to an approach that is more interdisciplinary and holistic.
“We’re rethinking our system,” Orwall said. “And how we really engage with people that are struggling.”
Seattle Times researcher Miyoko Wolf contributed to this report.