Nurses on the frontlines of behavioral health

Sisters of Providence circa 1860

Long before Washington became a state, the first official caregivers of people with mental health problems were immigrant nurses from Montreal. Often overlooked and forgotten, the Catholic Sisters of Charity of Providence opened “St. John’s Lunatic Asylum” near Fort Vancouver in 1861. Caring for the mentally ill was part of their charitable and religious mission.  

Today, nurses remain the largest providers of behavioral health treatment. Giving compassionate, quality care to people struggling with mental illness and substance use disorders, mental health nurses assume that families, friends, and others can no longer provide. Yet, they are consistently underpaid.   

In 1862, when the Washington Territorial Legislature awarded the Sisters a three-year contract to provide inpatient care for the mentally ill, it contracted to pay $8 per person per week. The Sisters took in private-pay patients because the government funding was so low.

Despite the low payment, the Sisters offered high-quality care. A notable component of the treatment was careful observation, helping prevent suicide or other harmful behaviors.  Consistent with prevailing treatment recommendations that a good environment would restore the mind, the Sisters offered housing in a beautiful, healthy locale.

Visiting St. John’s in 1863, Territorial Governor William Pickering was satisfied with the Sisters’ care; however, the Territory failed to make payments. The following year, the Territory made partial payments, offering devalued paper greenbacks worth only 50 to 80% of face value instead of the coin currency that Mother Joseph, the Superior, desired. The Sisters’ bill remained unpaid by the Territorial Legislature until 1872.  

Despite the lack of payment, the Sisters worked under the contract until 1866, when the Territory awarded the contract to lower bidders, a father and son partnership in Monticello. They transferred patients to the hastily built asylum lacking any nurses or physicians. Conditions at the Monticello asylum raised cries of alarm. An inspection revealed a “shameful negligence of duty” toward a female patient who had become pregnant. Patients lived in filth and standing water.

In 1869, the acclaimed nurse and advocate for the mentally ill, Dorothea L. Dix, visited our region. Dix spearheaded the opening of state-supported mental hospitals across the U.S. and Europe, using advocacy and her detailed first-hand documentation of asylum conditions. Learning of conditions at Monticello, she urged the Governor to remove the patients from Monticello. Worried that bad publicity could detract from the status of the new territory, the Legislature determined to open a permanent public institution with a resident physician. Later known as Western State Hospital, the new institution opened in 1871. Due to a lack of adequate state support, safe staffing, infrastructure maintenance, and quality of patient care, Western State lost federal certification and funding support in 2018.

Our historical experiences highlight essential questions about who will pay for the necessary treatment that our mentally ill brothers and sisters require. Privately funded initiatives, religious organizations, and charities can provide aid, but their goodwill and funding resources are limited. In 2019, Washington legislators approved legislation to improve our mental health system.

With the combination of the protracted COVID-19 pandemic, a worsening mental health crisis, especially for our young people, and half of the nurse workforce nationally burned out and considering quitting, we need to pay and support our nurses and our future nurses. From workplace violence prevention, safe nurse staffing laws, to pay parity for psychiatric nurse practitioners (SB 5222), we should learn from the past to ensure a better present and future.


Josephine Ensign is a professor of nursing at the University of Washington in Seattle. She is the author of Skid Road: On the Frontier of Health and Homelessness in an American City.

Mary K. Fleck is a former trial lawyer.  She is writing a book on the history of the Sisters of Providence in the Pacific Northwest.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.