Wednesday, 22 May 2019

Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry

By Lynn Nanos

The police found Owen, twenty-nine years old with untreated bipolar disorder with psychotic features, refusing to get off the road where he impeded traffic. Instead of arresting him, they escorted him to emergency services.

He gets readmitted to emergency services countless times within just a couple of months. His mother, Martha, tells me that he’s not been functioning at his baseline for the last four years. He started college, but now has no employment, no money, no friend, and no home.

Excerpt from Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry:

Owen’s chief demands of me include an apartment, money, food, and a photocopy of the entire Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). His rapid speech, restless body movements, inability to listen and concentrate, verboseness, and expansive affect are like what I previously witnessed. His outer physical appearance is like his appearance the previous times I saw him. However, I observe a more intensified level of torment radiating from his thinking and behaviors. He appears more out of touch with reality than ever before. He is mindlessly repeating my words, a behavior called echolalia.

His agitation increases as I write. He then demands that I read to him everything I write. He says that I’m writing lies about him.

I stop writing. In a brief silence that interrupts his talkativeness, I ask if he hears any voice that may not sound real. He says, “No!”

Fifteen minutes later, he voicelessly utters words for a couple of seconds. This is the first time I see him do this.

The revolving door that Owen and too many patients enter exists due to several combined factors. The nationwide shortage of inpatient beds creates a backlog of patients waiting excessively in emergency departments for placement. The involuntary hold criteria in most states are so restrictive that it is often difficult for patients to get the help they really need. Oftentimes, such laws don’t prevent danger.

For instance, in Massachusetts, a person can be transferred involuntarily to the hospital if he or she is at imminent risk of sustaining physical damage or cannot protect self from basic harm due to poor judgment. But psychotic deterioration is not considered. Nor is the patient’s lack of understanding that treatment is needed considered. When clinicians find that patients do not meet this stringent standard, there is usually no choice but to discharge them back home or to the streets. I propose that civil commitment criteria be revised to do more that reduce danger as it’s unfolding. Laws could be more proactive and preventative if they were expanded.

Breakdown exposes inpatient units discriminating against the most challenging clinical cases. If a patient determined to meet inpatient criteria is prone to violence, doesn’t want any help, has no health insurance, or is expected to present extremely challenging barriers to discharge, her or his wait for an inpatient bed will be longer than average. I boldly propose that consequences against inpatient units that discriminate against the sickest patients be imposed by the government.

The most common reason for treatment noncompliance is the lack of awareness of being ill, referred to as anosognosia. More than half of those with schizophrenia or bipolar disorder have anosognosia. The consequences of lack of treatment might be most pronounced in Massachusetts because it lacks Assisted Outpatient Treatment (AOT). In AOT, courts order outpatient treatment for people with serious mental illness who otherwise would not seek treatment voluntarily. This can include orders to adhere to prescribed medication, attend outpatient appointments, or both.

Despite the controversy of AOT in Massachusetts, where Breakdown is based, I bravely propose that AOT is expanded nation-wide. Despite the growing popularity and decline in controversy of AOT, it is still largely underutilized throughout the country. Extensive research shows that AOT reduces rates of homelessness, violence, hospitalizations, victimization, arrests, and improves self-care. Yet two other states, Connecticut and Maryland, also do not allow AOT. All other states and Washington, DC allow AOT.

About the Author

Lynn Nanos is a Licensed Independent Clinical Social Worker in her eleventh year as a full-time mobile emergency psychiatric clinician in Massachusetts. After graduating from Columbia University with a Master of Science in Social Work, she worked as an inpatient psychiatric social worker for approximately seven years.

She is an active member of the National Shattering Silence Coalition that advocates for the seriously mentally ill population. She serves on its Interdepartmental Serious Mental Illness Coordinating Committee committee and co-chairs its Blog committee.

Lynn can be contacted through her website

Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry is available in print and for Kindle at Amazon (COM | UK) and other sellers, including as an e-book from


Sunday, 19 May 2019

Mental Health Awareness Week Roundup

Hosted by the Mental Health Foundation, Mental Health Awareness Week took place from 13-19 May 2019. The theme this year was Body Image – how we think and feel about our bodies – and I thought it would be good to draw together some of the things we’ve been involved with.

There was a lot going on at work (BPDTS Ltd) through the week, including a number of excellent posts on our corporate blog. There was a company-wide dial-in call on stress, and a lunchtime meet and greet. I also attended a meeting of Mental Health First Aiders.

I was invited to contribute three articles, including one for the main DWP Digital blog.

Fran and I had the privilege of publishing two brilliant guest articles here at Gum on My Shoe.

Our friend and fellow mental health blogger Aimee Wilson posted a series of interviews throughout the week on the subject of body image.

We have some great content lined up here at Gum on My Shoe in coming weeks, including contributions by Lynn Nanos, author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry; and Katie Maylea, author of In Bloom Not Broken; so keep an eye out for those.

If you fancy working with us, check out the Guest Guidelines on our contact page.


Thursday, 16 May 2019

This Is My Body

By Charlotte Underwood

This is my body.

What I see:

  • Scars
  • Fat
  • Imperfections

What I feel:

  • Fear
  • Vulnerability
  • Disgust

What I know:

  • A body that’s kept me alive for 23 years
  • A body winning against binge eating
  • A body that is mine and no one else’s
  • A strong ass woman

The thing with body positivity and body image is that it’s hard work. Most people can’t stare at a mirror and force themselves to love what they see. Many people have a love/hate relationship with their body. But over time, we can learn to be proud of our bodies and our skin.

When I was a teenager, I literally stopped eating properly and I worked out a lot because I felt like I was being judged for my weight. I felt I wouldn’t be loved as a larger girl. And you know what? I wish I never had to feel like that.

I am learning to look after my body and my mind for myself. I do not let anyone tell me that I should lose a few pounds or sort out my appearance, because it’s not their right. Your body is yours, it’s keeping you alive and that alone is beautiful.

My rule of thumb: If you want tattoos and piercings, get them. If you want to dye your hair do it. If you want to put on makeup and a cute outfit do it. If you want to lose weight or gain weight, do it. Or Don’t. Whatever you need to feel more yourself do it, but only for you.

This post is brought to you by me being 100% wound up by society’s pressures to look perfect. Because I’m not ‘the ideal’. And what do I say that that? It’s my fucking body and it’s pretty damn great. I’ll enjoy it however makes me feel safe, happy and comfortable.

I feel like it’s important to mention:

  • I’ve still made great friends with this body.
  • I got married and found love with this body.
  • I still went on TV/did an ad campaign and photoshoots with this body.

Our body does not have to limit us, fuck what people think.

Please don’t ever feel like you are less of a person because society’s ideals have been thrown down your throat. Beauty ideals are simply an opinion. It doesn’t mean you are not perfectly beautiful and able to live and achieve a great life.

Also remember that when we die, our bodies will degrade but people will remember our actions and kindness.



Originally posted as a thread on Twitter, starting here.


About the Author

Charlotte Underwood is a twenty-three year old from Norfolk, UK. She is a growing mental health advocate and writer who aims to inform and education on mental health. The goal is to be a friend to those in need. She believes no one should feel alone. Charlotte blogs at You can also find her on Twitter and on Facebook.


Wednesday, 15 May 2019

Mona Lisa and Me: My Journey with Body Image

By Jen Evans

When I think about body image, the first thing that occurs to me is that women seem to have to deal with this more than men. But I’ve never chatted with a man about this subject so I don’t know how valid that is. On a daily basis, men and women are confronted with ideas and images about what they ought to look like on magazine covers and in the world of celebrity. In my thinking, all of these images are airbrushed and not realistic.

From the Middle Ages to the Renaissance, a larger woman was considered normal and of noble status because she could afford to feed herself. If we take a look at the Mona Lisa we can see that she’s no Twiggy. She’s full-bodied and buxom. That was what people considered attractive at that time.

Somewhere along the catwalk, I feel we went horribly wrong. Even in the Fifties here in America, women like Marilyn Monroe were more like an hourglass than a Barbie Doll. Maybe it’s because of ladies like Twiggy that the unrealistic body image manifested.

My journey with body image has been challenging. I’ve spent my adult life dealing with an eating disorder called binge eating disorder (BED). Until I was twenty-six I ate whatever I wanted and didn’t have to think about my weight. I was mostly happy with my body at this time. But around twenty-seven I started to use food to deal with complex emotions.

Looking back, a lot had happened to me before I turned twenty-six. I had experienced profound loss, from my parent’s divorce and my father’s abandonment of me, to the death of a beloved friend. And more poignantly, at that exact time in my emotional history I lost the guy I married. He wasn’t who he portrayed himself to be. He was someone else entirely.

At twenty-six I was too young to process all this. So I started to eat. Once I became a plus-sized girl I felt shame for my physical expansion. Also I was body-shamed with nasty stares by both men and women. I’d like to tell you it has gotten easier. But I can’t. I’m still a big girl and I still don’t like it. I body-shame myself all the time and I am not comfortable in my own skin.

There is a movement now where women are advocating for body diversity. It calls for acceptance of “fat” or larger people. I think that’s great. I do. But for me, it’s not simply a question of my weight. It’s not healthy for me to be bigger. I have two bad knees and when I’m big they hurt at times, specifically when going up and down stairs. I don’t like the way I feel when I’m big. I also feel it’s harder to attract a date when I’m heavier.

Really, I just feel bad about myself and that doesn’t help in any sort of way. If I could feel good about myself at whatever weight I was then maybe I wouldn’t think about it day after day as I do now. But it is a constant at this time, and so is my disorder. I’m hoping to truly deal with my food issues this summer. I want to be my best self and that doesn’t include weight, both physically and metaphorically. A healthy me will probably be a more grounded me, and that is what I will achieve.


Monday, 13 May 2019

I Wasn't Disappointed in You When

I wasn’t disappointed in you when your weight went up because you ate all the girl scout cookies. Although maybe it seemed that way when I suggested you throw them away or gift them to someone next time, and lectured you about average daily calories. As though that would fix your relationship with your body.

I wasn’t disappointed in you when you told me you cut yourself. Although maybe it seemed that way when I said remember I’m here. Don’t ever feel you’d be a burden or that I’d be too busy or asleep. As though I can make the demons go away.

I wasn’t disappointed in you when you went back to sleep after our prearranged wake-up call. Although maybe it seemed that way when I started calling a second time or a third to make sure you were up. As though your day starts better in my hands.

I wasn’t disappointed in you when you told me there’s no hope, no job, no friends for you so why bother trying. Although maybe it seemed that way when I pushed suggestions in your face you’d tried a hundred times before. As though my blazing positivity could make a difference this time.

I wasn’t disappointed in you. But maybe you were. And I didn’t honour that. I didn’t allow breathing space for that.

I need to sit with this a while.
Breathe it in. And out again.
Because I’m disappointed in me.
And that’s okay too.


Wednesday, 8 May 2019

Just Be Real. Let Profound Sort Itself Out.

I wrote recently how my blog posts are often inspired by conversations. The inspiration for this one was a recent online chat with a friend. We were discussing an article she was writing for Mental Health Awareness Week on the topic of body image.

“I’m interested to read your piece when it is ready.”

“I’ve only just started. I’m not sure I have anything profound to say.”

“Just be real. Let profound sort itself out.”

If you follow our blog you’ll know I’m a great believer in real, which I might also describe as genuine or honest. In life generally, but especially when it comes to writing. I would much sooner read a possibly-less-than-polished piece from the heart and guts of its writer than something which has been finessed but lacks integrity.

You can read more of what REAL means to me in this article hosted by HastyWords.

On one level, of course, an article, essay, poem, or any other piece of writing is REAL from the moment it’s written down. It exists in physical form, perhaps as words scribbled out on a page (as this one is materialising, word by word, in my Midori Traveler’s Notebook at a table in the lovely Church Gallery coffee shop in Kirkby Stephen) or on a screen.

And that alone can be enough. Bringing something into being is a profound act. It is art, and needs no further validation or justification. To create is to partake in and contribute to something greater than yourself. And if your words are written with integrity, if they are kind in mind and heart, then — oh! — they have the potential to move mountains. To move other hearts than your own. To change lives. Maybe even save a life.

And that’s about as profound as it gets.