As American cities deteriorate, a psychiatric nurse reckons with the high price of compassion
“So, what all did I miss?” she asked.
“Pretty much more of the same,” one of her co-workers said, as he turned on a projector screen and pulled up a complete list of their clients, 84 of the sickest and most vulnerable people in Seattle. Most of them had been chronically homeless before getting placed into subsidized apartment buildings downtown. Many suffered from severe psychiatric disorders, at least half were addicted to methamphetamine or opioids, several were homicidal and suicidal, and ever since the pandemic began altering the character of American cities, almost every one of them had been getting progressively worse.
“He assaulted his neighbor and started a fire in his room last night,” read a caseworker’s daily report about one of Naomi’s patients, as she took out a pen and began to write notes. “Delusional. Paranoid. Police and fire called to the scene.”
“Spotted walking through traffic wearing bizarre attire,” read another daily report, on her next patient. “Menacing, disheveled, open wounds to face and ear.”
“Using a bucket as a toilet,” read another.
“Lonely. Sent texts asking how to hold a gun in case she decides to shoot herself.”
For the last two and a half years, this was how Naomi and her team of caseworkers, clinicians and addiction specialists at the nonprofit Downtown Emergency Service Center had started each morning: by making a day-by-day accounting of the rising mental health crisis that had overwhelmed and transformed Seattle and so many other places in the country. Just like most major metropolitan areas, from New York to Denver to Los Angeles, the greater King County area had experienced a historic spike in homelessness, suicides, homicides and drug overdoses in the last few years, overwhelming its already under-resourced mental health systems. The average wait time for inpatient psychiatric treatment had risen to a record 44 days. The Seattle Police Department had lost 27 percent of its force in the last two years and was increasingly reluctant to intervene in any situation involving a mental health crisis because of new laws limiting use of force. The government-run crisis team that had once responded within hours to evaluate and detain people who were considered an imminent danger to themselves or to others was now backlogged by weeks or sometimes months.
“So many parts of the system are breaking down,” one King County politician had said, and that meant it was increasingly Naomi alone who responded to each of her patients’ medical emergencies, who tried to administer their monthly antipsychotic medications, who tested their drugs for deadly traces of fentanyl, who treated them for lice, who coaxed them into appropriate clothing, who counseled them through violent delusions, who was herself often threatened and sometimes assaulted, and who occasionally went to conduct routine welfare checks and found her patients dead.
And it had been Naomi again whom King County chose to represent all of its front-line health-care workers in August and September, when she stood alongside local leaders as they declared a citywide mental health emergency and proposed a $1.25 billion tax levy in part to fund five new mental health crisis centers. “We need to fix what’s broken, and I’m part of what’s broken,” she’d said from the lectern in August, and then two months later she’d taken the day off from work, sent a few goodbye messages, and tried to poison herself by overdosing on insulin. She’d spent three days in the hospital and five more in the psych ward processing all of her recent trauma, and now she’d come back to work to find out if what had happened to her and to her city over the last few years was in fact still fixable.
“Attacked his oven and other appliances last night in what he says was self-defense,” went the next daily report, and Naomi closed her eyes and counted her breaths.
“Refusing meds and making disturbing comments about children — concerning given his history.”
“Oh no. Not again,” Naomi said. She’d been visiting that patient in his downtown apartment throughout the pandemic, and when he was taking his antipsychotic medication, he could be charming and polite. But whenever he stopped taking his medication, he acted out in frightening ways around the city. He’d been arrested and briefly jailed for trespassing, use of a weapon, harassment, indecent exposure and at least a half-dozen assaults.
“I don’t want this to turn into the next major incident,” she said. “He’s really talking about kids?”
“Yeah. It’s not headed in a good direction,” her co-worker said.
“Do we have a plan?” she asked, and she looked around the table for a moment even as she realized she already knew the plan, because it was the same for every patient on her list. At least nine people were spiraling into full-fledged crisis, and she was the only nurse on her shift.
“I’ll go see what I can do to help him,” she said.
She’d spent the last decade working as a psychiatric nurse in the most destitute parts of the city because she thought every crisis could be overcome. She’d dealt with mental illness in her own family. She’d bounced through foster care systems and abusive relationships, and she’d been homeless in Seattle herself in the late 1990s before going back to school. Her life had convinced her that anyone was capable of getting better, but lately that belief was being challenged, because each time she went to see a patient she found herself preparing for the worst.
She put up her hair so nobody could yank it. She took out her earrings so they wouldn’t get pulled. She packed a bag of antipsychotic drugs and overdose-reversal medications and then drove downtown to a subsidized apartment building called the Morrison, with 200 units reserved mostly for people with severe and persistent psychiatric disorders. Outside the entrance, six people were huddled together smoking methamphetamine. A middle-aged man in the lobby was banging his head against a trash can. A woman wearing no pants stepped off the elevator, spotted Naomi, and started throwing punches at the air. “You African,” she shouted. “You filthy Nigerian.”
“Good morning, lovelies,” Naomi said, smiling and greeting each person by name. She walked deeper into the lobby and saw the patient she’d come looking for, the man who had been refusing his medication and having delusions about children. He was mumbling to himself, pacing and spooning yogurt into his mouth with his fingers. Naomi walked over and put her hand on his shoulder.
“Okay, my friend. What arm are we doing today?” she asked, hoping to catch him off guard and administer his shot of medication quickly, so there was no time for indecision or debate.
“Huh?” he asked. “Who sent you?”
“Nobody. It’s just time again for your monthly dose,” she said, as she pulled out a vial of the long-acting medication that helped to keep him stable and limit his delusions. “Right arm or left?”
He tucked his arms behind his back. “No way,” he said. “There’s bad stuff in there.”
“It’s the same medication you’ve been taking for years,” she said. “It’s been good for you.”
“You don’t understand. People are trying to kill me!” he shouted, and he slammed his yogurt into a trash can and hurried past her. Naomi put his medication back into her bag, walked into the office of the building’s clinical director and shook her head.
“No luck, huh?” Tim Clark said. He pulled up a file on his computer and showed Naomi the patient’s latest incident report, from a few days earlier: “He said, ‘Someone is poisoning me and wants me to hurt a boy. I don’t hurt children. I don’t want to. But she said that’s the only way she would stop poisoning me.’”
“He’s decompensating,” Naomi said. “It’s probably going to get worse.”
“What the hell do we do?” Clark asked. Before the pandemic, the plan would have been fairly straightforward. Whenever people became an imminent threat to themselves or to others, the staff at the Morrison would call for one of the designated crisis responders (DCRs), the only people in King County with the legal power to evaluate and then commit someone to mandatory mental health treatment. Usually, within a few days, the person in crisis would be evaluated and then probably hospitalized for weeks or often months, until they’d stabilized enough to return to the community. But now hundreds more people were in crisis all across King County, those crises were becoming ever more urgent, and the understaffed DCR teams couldn’t keep up with a record number of requests.
Their average wait time to evaluate someone exhibiting homicidal or suicidal tendencies in King County had tripled during the pandemic, to an average of 277 hours. The staff at the Morrison had been waiting two months for a crisis evaluation on a resident who often ran through the hallways naked and compulsively flooded her apartment with so much water and human waste that it ran down the hallway, into the elevator shaft, and through the ceiling in the main lobby, causing more than $60,000 in damage to the building. They’d been waiting several weeks for crisis response on a resident who kept threatening people with a pocket knife; and on another, who had spent four weeks walking around with a dislocated arm, his condition worsening as he remained too disoriented to accept treatment; and on another, who was hoarding garbage in his apartment and defecating on the floor.
It increasingly felt to Clark like many of his residents were being neglected by the system, left to suffer and unravel in any variety of horrific ways. Thirty residents had died inside the building since the beginning of the pandemic, more than four times the normal rate. Overdoses had doubled, and assaults were up.
“I hate that he keeps talking about kids,” Clark said. “I’d sleep a lot easier if he’d just take his medication. He’s capable of some pretty scary stuff.”
“We can’t force him to take it, but I’ll keep trying,” Naomi said. “I’ll come back every day. I’ll be here tomorrow.”
“But what about between now and then?” Clark asked.
“I’m going to try not to think about it,” she said.
Her therapist had told her she was suffering from post-traumatic stress and work-induced anxiety. Innocuous sounds startled her several times each day. Her hands sometimes shook involuntarily. “Clear evidence of both personal trauma and secondary trauma,” her therapist had called it. She’d suggested that Naomi consider changing jobs, but Naomi wasn’t ready to abandon her patients, so each morning she kept going into work with a list of people who required urgent care.
The next morning, she was back at the Morrison, hoping to try again with the patient who was talking about children. She knocked on his door and called out his name. “I’ve got your medicine,” she said, but he didn’t respond. She took out her notebook, put a question mark next to his name, and moved on to the next patient on her list.
It was a man lying shirtless in his apartment and compulsively rubbing his head. There was a dead mouse in his kitchen and a plate of rotting food in the microwave. “Why are you here? Did I start killing people or something?” the patient asked, genuinely confused, and then he started to cry. “No. You haven’t killed anybody,” Naomi assured him. “You’re doing just fine.” He refused to take his medication, so she picked up some of his trash and left the pills next to his bed.
Next on her list was a man who took off his shirt and kept trying to hug her as she gently pushed him away. Next was a woman who had overdosed two days earlier at a nearby public fountain. Next was a woman who refused to acknowledge that she had cancer and instead believed she was pregnant with 100 snake babies. Next were three more patients, who needed monthly antipsychotic injections, and then finally there was only one name left on her list — a patient suffering from paranoid schizophrenia who was five days overdue for his medication and had started harassing neighbors and punching walls.
“Can you come down to the lobby for your shot?” she asked him, over the phone, and to her surprise a few minutes later he was striding off the elevator, smiling at her, flashing a thumbs up. He followed her to a small room in the apartment lobby and rolled up his sleeves as he watched her prepare the shot. She showed him the label on his medication and explained all the likely side effects: drooling, vomiting, restlessness, headaches.
“I don’t like being scared,” he said.
“You’re safe,” she reassured him. “I’m here to help.”
“Just don’t poison me, okay?” he said, and as he watched her put on her gloves, he began to fidget and whisper to himself.
“Go away,” he said. “Shut up. … No, stop that.”
“Are you all right?” Naomi asked. “Do you still want to do this?”
He nodded at her and then clenched his fist and banged his thigh. “Get out of my head, idiot,” he said to himself. “Go away! … I won’t do that. … I refuse.”
“It’s just me here,” Naomi said, gently massaging his arm, as she looked out the doorway to see if anyone else was nearby in case he became more agitated. The lobby was empty. The person who usually sat at the front desk was outside smoking a cigarette. She tried to focus on giving the injection instead of thinking of all the ways during the pandemic that patient interactions had sometimes gone horribly wrong: The 14 times in the last year when she’d been pushed, grabbed, slapped, sexually harassed or verbally assaulted. The nurse in a similar job who had recently torn tendons in her shoulder while fighting off an attempted rape in a patient’s room. The Seattle social worker who had been meeting with a mental health client in her office in 2021 when he stabbed her 12 times, killing her.
And then there was the last time Naomi had been alone with this same patient sitting across from her now, just a few months earlier, when he’d looked at her with wild eyes and started growling and saying something she couldn’t quite understand. “What was that?” she’d asked him. “Are you a martyr?” he’d said, and she was confused. “What?” she’d asked again. “Are you a martyr?” he’d screamed, and then he’d gotten out of his chair, grabbed her shoulders and ripped off her N95 mask. He’d pinned her against the wall and pressed his hands against her face, repeating something about blood and sacrifice until someone in the lobby overheard the assault and pulled him away. “Oh, Naomi. I’m so sorry,” he’d said, a few moments later, once the delusion had passed. “Please don’t call the police. I’m sick. I need to take my medicine.” She’d accepted his apology and given him the shot, because that was her job, and now she’d come back to administer his medication again.
“Try to relax your shoulder,” she told him.
“To all the Gods and all the saints, please forgive me,” he said to himself, as he nodded and stared up at the ceiling. Naomi took a deep breath and raised the needle.
“No!” he shouted. He jumped out of his chair and stared down at her. She raised her hands and backed away. “It’s me. It’s Naomi,” she said.
He banged his fist against his knee. “Someone will pay,” he said, and then he turned around and ran out of the room.
A few nights later, she sat down for tea with her newest colleague on the nonprofit team, a nurse whom she’d started calling “White Jesus.” Josh Potter arrived from Tennessee a few months earlier with long hair, a deeply religious background and a pious selflessness when it came to caring for their patients.
“How are you feeling about this crazy job?” Naomi asked him.
“We get to care for some really broken people,” he said. “It’s about total nonjudgment and seeing the value in every human life.”
“Compassion. Harm reduction,” she said, nodding, because they believed in the same things. She drank her tea and looked at him again.
“But doesn’t it make you exhausted?” she asked
He shrugged. “Some days, but it’s something I believe in. We’re making a difference.”
“That’s how I used to feel,” she said, and then she started to tell him about the ways that both the city and her perspective had begun to shift during the pandemic, after commuters, tourists and even most other social workers stopped going downtown and many of her patients were left increasingly on their own without the adequate medical care or societal guardrails to keep their illnesses in check. She’d put on a mask, suffered through three rounds of covid and continued to visit her patients each day. Her team’s goal was to help people improve and then graduate to less-intensive levels of care, but in the last three years she could only think of a half-dozen patients who had graduated. “No wins and so many brutal losses,” she said, and she told him about the 19-year-old who had been found dead inside her tent, the patient who had jumped out a seventh-story window, and the 56-year-old whom she’d discovered in his apartment a few days after his death.
She had yet to tell her all of her co-workers about what had been happening to her during those months, even as she’d started talking to a therapist about the hardships of her work. She’d taken up crochet. She’d booked a vacation to Belize. She’d rallied her co-workers to fight for better working conditions. And when none of that seemed to alleviate her anxiety, she’d moved out of Seattle to a quiet condo in the suburbs with a view of a lake, where it turned out she still couldn’t get away from her fears, her depression or her rising sense of anger and hopelessness for both her patients and herself, until one morning in early October when she decided to call in sick. She stayed on her couch and watched birds fly over the lake. She ignored a phone call from work. She took out the insulin she used to treat her diabetes and decided in that moment to give herself several times the normal dose, which made her start to feel dreamy and numb. She texted a co-worker to please take care of her cat. She texted her sister goodbye. She took another massive dose of insulin, which made her blood pressure drop as she slipped in and out of consciousness, and the next thing she remembered she was riding in the back of an ambulance with paramedics who explained that her sister had probably saved her life by calling 911.
“Sorry you ended up with a nursing partner who’s such a hot dumpster fire,” she told Josh, and his smile seemed so kind and understanding that she told him what she’d been thinking about over the last several days. The doctors in the psych ward had recommended a partial hospitalization program to help her deal with trauma, which would require her to leave work for at least a few months. Maybe she’d come back after that, or maybe she’d look for a different nursing job where she could see more evidence of healing.
“I have nothing left,” she said. “I need to go away for a while.”
“Get yourself right,” he said. “Take some time.”
“I know it’s what I need, but I’m not sure how I’m going to do it,” she said. “I’m a psychiatric nurse. That’s who I am. We have all these people suffering, and I’m just going to leave them behind?”
“You can’t help anyone by running yourself into the ground,” he said, and she nodded and then thanked him.
“I have a few things I still need to do,” she said.
Early the next morning, she drove back to the Morrison and saw an ambulance and a police car parked outside. “Oh, no,” she said. She hurried to the elevator and took it up to the room of the patient who had been having delusions about children and then knocked on his door.
“Hello? It’s Naomi,” she called out. She waited a few seconds and then knocked again. She leaned into the door to listen, and she heard the sound of shuffling feet and then footsteps coming closer in the hallway behind her. She swung around and braced herself.
“Good morning, Naomi,” said one of the building’s employees, smiling and carrying a cup of coffee.
“Oh, God. You scared me,” Naomi said. She pointed toward the apartment door. “Have you seen him? I noticed the police outside.”
“Oh, that was for someone else — a fight in the elevator,” the employee said. “But I did see him a while ago wandering around upstairs. He needs that shot bad.”
She thanked him and went upstairs to another apartment where her patient sometimes went to use heroin, and where he’d overdosed and been revived by a friend a few months earlier. The door was partway open. She called out, but nobody answered. “God, I hate this,” she said. She reached into her bag to locate her overdose-reversal medication and then peered through the door, half-expecting to find her patient on the floor. She could see four used syringes on the kitchen table and dozens of fast-food wrappers scattered across the ground. A handwritten sign had been taped to the wall: “Home of the forgetful and the forgotten.”
“Anyone here?” she asked, and she was about to step into the room when her cellphone rang. It was one of her co-workers, calling to tell Naomi about another patient who said she was being held captive in her apartment by a man who wanted to hurt her. “Is it real or a delusion?” Naomi asked, and the co-worker said she wasn’t sure. “I’ll go check,” Naomi said, but before she could hang up, the co-worker started telling her about another patient, who was running naked in a public stairwell. The woman’s landlord had notified the county’s designated crisis responders, but they said they wouldn’t be able to come for at least another week.
Naomi hung up and tried to decide which emergency to respond to first, but before she could make up her mind, she heard a door open behind her and saw the patient she’d been searching for step out into the hall. He was shaking his head erratically and mumbling to himself.
“Hey!” she said, trying her best to sound cheerful.
“Get lost,” he told her.
“Get the hell away from me! I’m on a mission,” he said, as he clapped his hands and rushed by.
“I’m trying to help you,” Naomi called out, but all she could do was watch as he went out the doors and into the city. She stood alone in the hallway.
“How am I supposed to fix all of this?” she said.