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 lynnanos.com.

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 lynnanos.com.

 

How Writing a Memoir Has Helped Me Talk More about My Mental Illness

By Peter McDonnell

I’m going to dive right in and begin. I hope people with similar problems with psychosis and anxiety can relate. Since writing a memoir of my experiences with psychosis, anxiety and recovery I have found that I can talk much more easily about my mental health issues.

Before I began my memoir in 2015 I had no interest in sharing how I was feeling about my illness with my supportive team (my parents who are both qualified psychiatric nurses, my various psychiatrists, my care coordinators etc.), friends, family and work colleagues. Now, just try and shut me up!

I often have to remind myself in general conversations that though my mental health and recovery fascinates me, other people are usually not as interested in my experiences as I am (but sometimes they are!). I had my annual appointment with my psychiatrist two weeks ago. She asked how I was, and so I began.

I am doing really well. I’ve been a bit blocked up with constipation – I understand that my medication (Clozapine) can sometimes affect this. I’ve been eating lots of fruit and veg and I bought some prune juice earlier today, so I expect the prune juice to work and I should be fine by tomorrow.

My anxiety is still improving, it’s at such normal levels now that I’m not really thinking about it and I’m not sure it’s any higher than what normal people get from time to time.

But I am wary that I’ve been challenging myself less recently. My nieces and their parents lived in London until a few months ago before moving to Denver, and taking the train or driving up to see them fortnightly was a challenge that helped me keep my abilities to stay on top of anxiety I think, and I do wonder sometimes if not having this regular challenge might make me rest on my laurels a bit and get too comfortable. For the last few years I have found that remembering to keep well is sometimes very important and if I forget to, I feel a certain dip in my general mental health.

I keep well by doing a mix of little and big things. Sometimes it’s just a case of asking my brain in the morning what kind of positivity I want to feel that day, and for reasons unknown to me, it works and eight times out of ten at the end of the day, I find that I have felt exactly how I told my brain I wanted to feel!

Other times I have found it helpful to push myself a bit and do more challenging things, like spending the day looking after my nieces in London. They lived in Chiswick and I’m very close to them, they are two and four years old. I think looking after them taught me responsibility and some of how to be a mature adult, and after doing the parenting thing for a bit, whether for an afternoon, overnight or for a few days and nights I felt very in step with the world.

It’s at this point that the doctor senses that I am doing well. I sense her sensing it. I then decide that I have more to say.

My psychosis and ideas of reference are still there, but I am controlling them well. I used to feel like people in queues and waiting rooms could read my thoughts, but it’s happening less recently. When it was bad I’d be standing behind someone in a queue and my ‘Telepathic Tourette’s’ would start and if the person in front of me was very ugly, then I’d hear in my mind “fuck me aren’t you ugly” and because of my stupid and annoying telepathic abilities (that I don’t think I have anymore) I’d think they heard me.

Then in my mind I’d feel like I had to explain to them, telepathically, that I don’t really think they are ugly, even if they looked like a Hyena. I am a nice person who doesn’t insult the afflicted; I’m not a ten out of ten myself!

But then like Tourette’s syndrome all the other insulting thoughts come out and the people around me can hear them, like ‘you’re a prick with a stupid haircut’ or ‘you smell like a landfill site’. It’s annoying, but recently it hasn’t been a problem and thoughts are appearing in a softer way in my head in these situations, so that’s a good bit of progress.

My job is going well, I used to get anxiety at work a few years ago, but I don’t anymore. My mental health memoir and website is coming along, I recently had a friend with lots of Facebook friends share a link to it and I got 2000 visits in four days. I have been working with a website guru to improve my website which is going well too.

By this stage my Doctor begins indicating that she isn’t interested in a haphazardly scattered lecture and that she has other people to see. So I wind it down and she does the usual thing, checking that I am still taking my Clozapine without any problems and she says that we could do a full check on everything via blood test, a sort of annual check-up of glucose levels, lipids, Amylase, B12 and calcium etc. She says that I seem to be doing very well. She gives me a blood form to take to the phlebotomist and we say goodbye.

I throw her an accidental curve ball as I remember that I wanted to ask if she could recommend a popular online psychosis journal that I might write a paper for. She says “No, sorry – but good luck with your writing, Peter”.

So that’s how I tend to speak to my psychiatrist. I hope it shows that a person can be comfortable talking about whatever they like to them. When you are ready, open up.

I rarely opened up to people about my mental health before I started writing about it in my spare time. For me it wasn’t really stigma or the taboo factor that made it difficult to talk. It was that the words were hard to find. It’s not easy to talk about why a panic attack may have started, or the processes involved with bringing about a period of good mental health, and often it’s complicated to answer a simple question like ‘how are you’ when you are at the doctor’s office. One is supposed to elaborate when they are asked how they are by their psychiatrist. In regular daily exchanges ‘fine thanks’ is sufficient.

If you are like me and have or have had limited social conversations due to staying at home a lot, because of anxiety issues perhaps, then the power of descriptive speech can begin to fade. Lots of people get embarrassed when discussing their mental health too.

Before I wrote my memoir, talking about the finer points of my mental health often felt like a fruitless endeavour – an impossible task. I felt like I could talk if I wanted to, but that there was no way I’d find the words to be understood properly. For many years I had very little insight or understanding of my illness. It felt like there was no way my team could understand it any better by me talking about it, because I didn’t even understand it myself.

But these days I talk about it all the time and talking is helpful for mental health for hundreds of reasons. So helpful in fact that there is a phrase assigned to the action of talking about mental health – ‘talking therapies’. Talking can help you take charge of your well-being.

The thing that allows me to verbalise it all is my writing. I have been writing about my mental health and recovery for at least four years now, including a book, articles like this one, papers for online mental health journals, travel articles and my blog. Writing has instilled a sense of enthusiasm, so now I find that my mental health and mental health in general (especially how my own experiences with mental health compare with other peoples) is my favourite subject. I can also find the right words when I need them and I am keen to pick up knowledge and tips through conversation.

If you want to use talking to feel better about your mental health I would recommend writing a journal of your thoughts about your mental health at the end of each day. Then when someone asks you how you are, either a friend at work or your psychiatrist, you will remember your journal and feel like you have some thoughts to share. You will often feel more enthusiastic and the words will be ready to go on the tip of your tongue.

About the Author

To read more of Peter’s writing about his journey with mental illness and recovery visit his website petermcdonnellwriter.com which has extracts from his memoir, articles written for other websites, his blog, a guest post page and more.

 

Always Unstable: The Book, by Meghan Shultz

Always Unstable: Bipolar and Hospitalisation: A Memoir is a book that was a long time in the making, 26 years in fact. I started to write it after my second hospitalization within a year. I felt like I had a lot to share, a lot to own up to, and a story to tell that maybe others might find interesting or helpful. I was already running a blog but I wanted to do something more. I had a bigger story to tell, one that couldn’t be contained within a blog post and one that I didn’t want to draw out over a series.

The main focus of my book is my five hospitalisations over the last ten or eleven years. Psychiatric hospitalisations. Although I probably don’t need to clarify that. The first one was when I was 15, I had tried to kill myself, unsuccessfully much to my dismay. The second one didn’t come until ten years later, it was soon after I was told that I had Bipolar Disorder. I was hospitalised for a Bipolar mixed episode. Next was the mania and the eating disorder, then the electroconvulsive therapy and, probably not the last, the psychotic manic episode.

With this book I take you through all of those hospitalisations, what lead up to them, what happened while I was hospitalised and what happened afterwards. I’ve censored nothing. I talk truthfully about my experiences with a failed suicide attempt and self harm. I talk about losing a lot of my teenage years to addiction. I talk about spending hours hunched over a toilet when I struggled with an eating disorder. And I talk about my experiences with 15 rounds of ECT. Because why write if you’re not going to be honest? Why tell your story if you’re going to censor the parts that you’re ashamed of? And believe me, I’m ashamed of a lot. But it’s all in there.

I am so proud that I wrote and finished this book because I rarely see things though. That’s the bipolar in me I suspect. But this was different. I feel like writing is in my blood, coursing through my veins forever more alongside the Bipolar. Writing this book was very therapeutic for me too. I had a lot of shit to get off my chest, a lot of stuff to own up to and make peace with. There are also some people that deserve to know the truth and what I live with on a daily basis. Those people are my husband, my parents, and siblings, the ones that have lived with me for so long, the ones that have seen the true effects of my illness. I partly wrote this book for them.

What I really want out of having published this book is understanding, relating, and non-judgment. I want people that struggle and live with mental illnesses to know that they are not alone, they are not the only ones going through these troubled times. There are millions of us. Now, understanding. For people who don’t have a mental illness it can be really difficult to understand someone who is mentally ill. No matter how hard you try to understand it has to be something that you go through to make sense of it. But you can be there for them. You can offer a helping hand or someone to listen to or sit with them. You don’t have to fix us, just help us. And sometimes it’s just the little things that count. Example, my mother bought me a stuffed bear the other day, it brightened my day immediately. Non-judgment. Basically, don’t be an asshole. Don’t hear someone’s story and assume they’re a bad person. Example, when I was a teenager I was an addict. Am I a bad person? No. I have an illness which is prone to substance abuse and I was self-medicating. I was never a bad person.

So whether you’re mentally ill and can relate or whether you’re mentally well, I hope that everybody that reads this book can learn something and take something away from it.

 

About the Author

Follow Meghan on her website/blog, Twitter (@alwaysunstable), and Facebook (Always Unstable). Her book Always Unstable: Bipolar and Hospitalisation: A Memoir is available on Amazon.

 

How to Write A Status Report for Your Friend’s Psychiatrist

Supporting someone who lives with mental illness can be challenging, but there is a great deal you can do to help on a practical level, whether you live nearby or—as Fran and I do—on opposite sides of the globe.

Something I am able to do for Fran on a regular basis is write a Status Report for her to take to appointments with her psychiatrist.

This helps Fran because she often finds it difficult to recall details, especially if she has been fatigued or depressed. She also values having another person’s perspective. She sometimes asks other friends to offer their impressions of how well—or otherwise—she is doing, but I am best placed to provide an ongoing perspective, because we are in touch on a daily basis.

I welcome the opportunity to contribute to her care and support team. They value my input as someone who knows Fran well and can provide additional input.

I prefer to write my report on the day of her appointment. I start from her current status, as I see it, but also refer back over the period (usually between two and four weeks) since her last appointment.

There is no set structure, but I generally bullet point my comments and observations under the following headings.

What’s Happening
A snapshot of what is going on for Fran at the time, listing any key events, successes, or concerns.

Physical Health
In this section I focus on Fran’s levels of fatigue and pain, how she has been sleeping (insomnia can have a major effect on her other symptoms), and any other physical symptoms she has experienced recently.

Emotional Health
Fran’s general emotional state, for example whether she has been feeling flat, irritated, frustrated, or angry; or positive, motivated, and engaged.

Mental Health
Here I note any red flag behaviours we have detected which might suggest she is slipping into either mania or depression; also whether suicidal thinking has been as issue recently.

People and Connections
Relationships are important to Fran, and a good indicator as to how she is doing generally. I list any significant positive or negative experiences she has had with friends or other people recently (whether locally or online), inviting Fran to explore these further during the appointment.

Anything Else
Anything that seems relevant which I have not mentioned elsewhere, including projects Fran might be working on, upcoming trips or challenges.

Have you ever considered or been asked to write a Status Report for your friend or loved one? Would you be interested in doing so? We would love to hear you thoughts.

Marty

 

Maine Voices

Reach out and show you care. Friendship is good medicine and being present is the greatest gift of all. (Fran Houston)

Fran’s op-ed article Maine Voices: Time for mental health awareness was published in the Maine Sunday Telegram on October 4, 2015, marking the start of Mental Health Awareness Week.

In it she described her history of mental illness, and her experiences working with psychiatrist George McNeil.

Dr. McNeil gave me what I needed most — the sense of being heard.

Somehow, I learned to be human again. Somehow I began to create habits for myself and grew a life I wanted. As my self-worth got woven together, I began to care.

With Dr. McNeil’s help, I got better. I am not cured. My moods still swing. My symptoms still flare. But I now know how to surround myself with good souls who hold my hand while I try to balance on the seesaw of bipolar disorder. And I have tools in my wellness toolbox.

Fran’s heartfelt account resonated with many who read it. One wrote to her:

This is a powerful description of what you have gone through and manage all the time. If it helps one person who reads this, you have achieved what you want, and if it enlightens one person about mental illness, that is equally important. This is a piece that should be shared to reach many more people. To have shared your experience is powerful in itself. Your testimony about your doctors should also help to encourage others to seek out medical care. We all need to be open to discuss this. (Liz Wagner.)

The article was shared widely. We would like to thank the following in particular:

Maine Behavioral Healthcare (“Great article!”); Family Hope (“Fantastic article by Family Hope friend, Fran Houston. We are always amazed and appreciative of her openness to share her total self with the world.”); Catching Health, with Diane Atwood (“Beautifully expressed by Fran Houston, a woman with many gifts to share.”); Bob Keyes, journalist (“Courageous column about mental health awareness by my friend Fran Houston.”); NAMI Maine (“Well said!”).

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Note: “An op-ed (originally short for ‘opposite the editorial page’) is a piece typically published by newspapers, magazines, and the like which expresses the opinions of a named author usually not affiliated with the publication’s editorial board.” (Wikipedia.)

the big sea.. the big see..

I reached the pinnacle of a successful engineering career after a chaotic childhood, a rape, a cult experience, a violent marriage - only to plunge headlong into losing everything I’d gained. Mate, family, home, work, dog gone. Health gone. 1994. Major depression. 34 years old. I no longer knew who I was. I did not know how to go on. Frantically clawing my way I tried to regain my health, spending over $10k, desperately following any advice given. It didn’t work. Nothing worked. I lived in the Maine woods for a year. No running water. No electricity. No TV. No Radio. No books. No journal. Only dancing naked in the rain, snow angels under a full moon, watching frost freeze on the window pane. I was sleeping but no beauty. Twenty hours of unrefreshing sleep a day found my baseline chronic fatigue syndrome. The pain of fibromyalgia remained unrelieved. The cherry wallpaper was no consolation. Maddening.

I moved to an island. Peaks Island. Living in the old generator shack that once ran the Ferris Wheel. Sunsets were intoxicating. Dad died on Halloween, the thinnest veil between two worlds, and an aurora borealis. Easy and beautiful just like my dad. I lost my mind. Consumed with thoughts of jumping off the boat, a new friend said, “Why don't you?” My high gear got even higher. That’s how I landed at McGeachey Hall and entered your fishbowl. So many eyes on me while I told story after dramatic story. Angrily, sadly, crazily. Working with you gave me what I needed, a sense of finally being heard.

I began weaving together wisps of life in this magic place. Photography, writing, becoming an active member of the community. Making my regular boat trips to visit you. Telling you all the stories. It always felt more like a social visit than a therapy session. It was funny. I would come in all bent out of shape in fighting mode and 45 minutes later I’d be a lamb and truly feel better. Of course it would never last because illness always crept back in. I couldn’t figure out what you had done but it didn’t matter, I kept coming back. I was drawn to something of normalcy, kindness. I felt valued, worthy, honored. You never made me feel less than.

Of course I wasn’t always a lamb. You would ask me how I felt. I always answered “sad”. You would ask if I was angry. I always denied it. And get pissed that you asked. Rage was a staple. I could be a raging lion or tiger or bear, with words that spewed into my journal or out all over my friends. My mind was not capable of understanding the wholeness I was being offered. It was a sieve that everything leaked through. The battles my thoughts had with each other were nasty. Deadly, even.

I felt like Helen Keller. A wild child. We went through many drugs. I begged for more. You were always conservative while my friends’ doctors ripped through prescriptions. Each new change brought side effects lasting weeks or months, creating even more insanity. Now and then I’d get a good drug working, only to have it fail. Over and over, again and again. You always encouraged moderation. I always resisted. Remember when I almost fired you? That was rough for both of us. Something deep inside wouldn’t let me leave. There was a wisdom that bypassed my broken mind. I was safer with you.

The simple act of taking my coat at the beginning of each and every visit was unnoticeable at first. I was unaware of the effect, but there was care, worthiness and chivalry. You repeated the word “hygiene” for as long as I could remember. I had no idea what it meant or how to do it but in the later years of our therapy it slowly crept in and I remember just getting it one day. Somehow, I learned to be human again. Somehow I began to create habits for myself and grew a life I wanted. As my self-worth got woven together I began to care.

In one lucid and defining moment I made you a promise. I did not promise never to take my life. I promised I would call you first. It was an eye to eye, soul to soul commitment unbroken. I have since integrated hesitation practice with the mantra “not yet” into other parts of my life. It frees me to be more choiceful. Freedom. Choice. Response-ability.

You told me, “I can't save you, only you can save you,” and I was pissed off for years until I got it. There are things you are responsible for, and things I am responsible for. There are things I have control over and there are things I so very much do not. Wisdom is to find that edge and allow others to help you stabilize, and manage as best you can while the illness takes you up, down, all around. It’s like sailing on the ocean. There is stillness. There are storms. There is sun. There is rain. Intense and quiet. It is about weathering whatever the storm brings and believing you can make it, because someone has believed in you.

I am not cured, fixed, or healed but my life has been enhanced by our mutual knowing. My moods still swing. My symptoms still flare. But I now know how to surround myself with good souls who hold my hand while I try to balance on the seesaw of bipolar. I have tools in my toolbox. I have patched together a life that works.

You have held my hand to walk through some tough places. And you never once stopped believing in me. Being present is the greatest gift of all. That is good medicine. There is enough of me on board now.

Sail on..

Fran

[An open letter to my psychiatrist on the occasion of his retirement.]