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


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