Lynn Nanos is the author of the new book Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry. She is a psychiatric social worker in Massachusetts.
Q: In the preface to your book, you write about a tragedy
that was part of the inspiration for you to write Breakdown. In what ways do
you hope the book helps to change the system of emergency psychiatry in this
country?
A: As an inpatient psychiatric social worker, I tried to help
a patient with psychosis who refused to accept treatment because he didn't
believe he was ill, called anosognosia. I had a one-way conversation with his
mother and couldn't give her any information because he refused to sign a
release of confidentiality.
Since she had been living with him, she reported about his
deterioration over the last several months, including an uncharacteristic
assault against her. Despite my passing on to the psychiatrist her report, he
was discharged to her home in less than a week. Shortly thereafter, he stabbed
her to death.
I wrote Breakdown to improve care for the most seriously
mentally ill population, particularly those with psychosis. This group is
typically considered more difficult and expensive for agencies to treat, thus
the system often neglects them. Many of them are not able to independently
initiate treatment or formulate treatment plans due to anosognosia.
Q: You describe the emergency psychiatry system as “broken.”
How did it get this way, and what do you see looking ahead?
A: Beyond insufficient involuntary hold laws, the revolving
door of the system - the rate of readmission to inpatient and emergency
services is astronomical - is the most obvious sign of a broken system.
Before patients are admitted to inpatient units, many are
repeatedly discharged to their homes or the streets from hospital emergency
departments. Patients are not sufficiently stabilized when they are discharged
from emergency departments and inpatient units prematurely. Consequently, they
can end up homeless, jailed, harming others, or even dead.
Since the 1950s, well over three-quarters of inpatient beds
got eliminated. Then in the 1970s, state laws that allow involuntary transfer
of patients to hospitals due to their risk of seriously harming themselves or
others became more restrictive.
In recent years, Assisted Outpatient Treatment as a remedy
has become more accepted and widely used. At its best, judges order the sickest
of the sick to adhere to treatment recommendations, often involving medication,
or face the possibility of involuntary hospitalization.
Currently, only three states do not allow Assisted
Outpatient Treatment - Massachusetts, Maryland, and Connecticut. I expect that
these states will adopt this type of treatment in upcoming years.
Q: Who do you see as the readership for this book, and what
do you hope they take away from it?
A: Breakdown can be validating and comforting to families of
this population, who might feel isolated and frustrated with the dysfunction of
the system.
My hope is that the book lands in the laps of state and
federal government employed clinicians, as well as legislators, who have the
power to make changes.
Q: In the book, you describe the Assisted Outpatient
Treatment program. What role do you see it playing today?
A: Breakdown promotes Assisted Outpatient Treatment which is
underutilized or not used at all in states that allow this. According to
countless sources that I cite in the book, this form of treatment has proven
effective in reducing rates of homelessness, incarceration, hospitalizations,
violence, and poor self-care.
I regularly witness the consequences of Massachusetts not
allowing this in my role as an emergency clinician. For instance, I've helped
many untreated patients who got evicted because their paranoid delusions caused
them to disrupt their neighbors or their profound disorganization rendered them
unable to make rent payments.
Q: What are you working on now?
A: I am an active member of the National Shattering Silence
Coalition that advocates for the seriously mentally ill population. I’m part of
their committee that advises the Interdepartmental Serious Mental Illness
Coordinating Committee.
Since the beginning of 2017, this committee has been
initiating better federal coordination of government departments intended to
serve the seriously mentally ill population and using advanced research to
promote evidence-based treatment for this population.
I’m also part of the Coalition’s new blogging committee, and
our first blog will get released soon.
Q: Anything else we should know?
A: One of the goals of Breakdown is to open a dialogue about
whether patients have the right to be psychotic. Some state that they have the
right to be psychotic and do bizarre things, and that the civil commitment law
should only be enforced if someone is about to imminently die.
But the problem with that is it’s not a preventative
approach and people without treatment can kill themselves or others. The
patient who killed his mother noted above was discharged quickly because the
law in Massachusetts doesn't consider the need for treatment.
I urge states to model their commitment laws after
Wisconsin, which considers the need for treatment. Assisted Outpatient
Treatment should be used more often and made available nationwide. We would see
more treatment and fewer tragedies if these measures were taken.
--Interview with Deborah Kalb
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