Breakdown: An Interview with Author and L.I.C.S.W. Lynn Nanos

Lynn Nanos recently debuted her book Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry. From her site, “Breakdown opens a dialogue with anyone interested in improving the system of care for the seriously mentally ill population. Using vignettes based on real interactions with patients, their families, police officers, and other mental health providers, Lynn Nanos shares her passion for helping this population. With more than twenty years of professional experience in the mental health field, her deep interest in helping people who don’t know how to request help is evident to readers.”

After seeing her ad on Facebook I decided to contact her to see if she wouldn’t mind me interviewing her for BipolarBrave. I am intrigued with the idea of fixing a broken mental healthcare system that I know exists from firsthand experience. Her book is available on Amazon and you can preview it and buy your copy here. She wrote the book in order to “benefit anyone interested in seeing a glimpse of the broken mental health system way beyond the classroom. It can guide legislative officials, family members, mental health professionals, and law enforcement officers toward a better understanding of the system.”

 

 

 

Katie: I read those first three chapters and was hooked. You write well. Could you explain the title of the book and what you mean by Breakdown and Emergency Psychiatry?

Lynn: Breakdown has a nice audiological ring to it and I was trying to think of a word that most describes the system. The system is a mess, and if you look up “breakdown” in the dictionary, it’s exactly what breakdown is. Also, a lot of clients when I interview them say, “I’m having a breakdown.”

Mobile emergency work involves evaluating people anywhere – I see people not just in hospital ER’s and medical units, I see them anywhere in the community where the crisis is happening. In other words, I see them only in certain towns and the evaluation takes place in police holding cells, personal homes, residential programs, doctor offices, my office, street sidewalks, homeless shelters — basically any place you can think of it’s possible to have an evaluation. My main role is to determine if people need to be hospitalized, and if I find they don’t need hospitalization, I refer them to various levels of care. For example, partial hospitalization programs, or maybe they need a new psychotherapist, or psychiatrist. Other times they need someone to talk to and the interview itself is helpful and that’s all they need. So giving them a chance to organize their concerns and talk to someone and get a little extra support.

Katie: What does the “I” in Licensed Independent Clinical Social Worker mean?

Lynn: The “I” in L.I.C.S.W. is the most advanced type of social work possible and it’s particularly helpful if I wanted to go into private practice (which I’d never do), but If I went into private practice, insurance companies would be able to reimburse at much higher rates. Lots of states don’t have the “I” at all. The highest level is called L.C.S.W., but Massachusetts throws the “I” in there. I took two exams after graduation. The first was immediately after graduation which enabled me to become an L.C.S.W. and then after supervision I took another exam which got me the L.I.C.S.W. And the advanced type of social work enables me (at least in Massachusetts) to authorize involuntary transports to the hospital.

Katie: In Missouri, it sounds like something the police would do here, or a judge.

Lynn: The police very commonly interact with very sick people.

Katie: Do you work with the police alongside them?

Lynn: I do, most of the police cases involve psychosis. I get a lot of referrals from police officers.

Katie: So let me take a step back. How did you get into this field of work?

Lynn: I’ve always felt really comfortable working with the sickest of the sick, and I have a lot of sympathy and empathy for their plight because I’ve increasingly noticed that they are most neglected by treatment providers and by the government. For instance, it’s a lot easier for someone pretending that they’re suicidal to get into an inpatient unit, than for someone who is prone to violence because of psychosis. I talk a lot about discrimination in my book. A lot of inpatient units, if not all, discriminate against challenging cases, and that motivates me to advocate for them. It’s very tragically ironic that those who need the most help seem to be the most neglected.

Katie: That’s such a paradox to me. Part of my story is that I went into inpatient care voluntarily. I wasn’t violent or suicidal, and I wonder now because it’s hard to get admitted if you’re not. I don’t know the exact guidelines and some states have a 72-hour hold law – and you talk about that in Section 12. You talk about “imminent risk”. Is Imminent risk the basis for why someone is actually admitted?

Lynn: You’re reminding me now of how I almost called my book “Imminent Danger” but I decided against that because there are chapters devoted to Borderline Personality Disorder, many of which don’t need to be hospitalized and another chapter devoted to malingering (they lie because they’re on the streets, hiding from the law, taking beds from people who need them). Civil commitment laws vary from state to state. Massachusetts has the most restrictive, I’m sure there are other states that are similar, but it varies drastically. So, the civil commitment law in Massachusetts doesn’t do anything to prevent danger – it requires the danger to be unfolding already.

There are civil commitment criteria. It’s extremely restrictive in Massachusetts, whereas some states consider whether someone has been deteriorating in the last couple of months, whereas Massachusetts law does not. The law requires involuntary hold if someone is going to be harmed, or, if serious injury or death were to occur because of lack of treatment. Another reason it’s so hard to get admitted is the shortage of inpatient beds. They may wait for days in the hospital ER and feel better, and decide they no longer want to go inpatient. After a few days the doctor and myself can think that as well, or find that inpatient care is no longer needed. Then the person follows up with outpatient treatment. So these are some reasons why it’s hard to get admitted to inpatient.

Katie: It sounds like there are so many moving parts with the way people are admitted. There has to be enough beds, private pay insurance, Medicaid or state insurance that will pay. I’ve heard where it’s described like the hospital gets paid based on quantity of people they can admit over a number of days, like a revolving door. If you get someone admitted and on the right medicine or as close to the right medicine as possible for a few days, then discharge them, and they’re not getting paid on length of stay but just admissions.

Lynn: That’s exactly what happens. They often get prematurely discharged, driven by the hospital wanting as much revenue as possible.

Katie: Does that depend on insurance on the patient’s side, say if I had a good insurance company for the length of stay or does all insurance pay the same?

Lynn: It depends on the insurance. Some have really bad insurance, others have generous. I find that when I’m presenting cases to insurance companies, trying to get people authorized for care, some are horrific insurance companies, and others are really good.

Katie: Maybe that’s why I was admitted so quickly, because my husband is military and we have Tricare. I was in there 10 days and some people I saw in there were only in there for three days and then discharged.

Lynn: So you were really lucky.

Katie: I didn’t like the stay, I don’t agree with putting a bunch of people that are in the state of mind they’re in, all together in a secured confined setting (that’s my issue with the way the system is), as there are so many people in such a small place and in the state of mind we’re in,  we’re so off the hook. And to be there, though I was voluntary admission, once I was admitted I didn’t want to be there at all. I was more traumatized by the experience than I would have been if I were at home or in a smaller setting. But that aside, yes, I was fortunate to have the insurance through my husband. It just frustrated me because some people got to go home after three days and I really wanted to go home because it was such a bad place.

At least when I was 24, I stayed at a couple hospitals and the people there didn’t care for the patients and treated us like second class citizens, but of course I wasn’t in my right mind and I was the patient. When they’re setting one clock an hour on one wall and the other was correct, or when they asking for my wedding ring for safe keeping sake, that bothered me. I don’t know what that was about. I just felt uneasy about the whole situation, even looking back today I feel like I was discriminated against. I didn’t see a doctor for days on end, so I have a lot of deep-seated angst toward how I was treated in the hospital. I want to be a part of the solution where we can communicate that the system is broken and needs to fixed.

So can you tell me more about the breakdown of the system, besides the way people are admitted and insurance companies? Do you work on the inside or just admissions?

Lynn: Just on the entrance way, but I was an inpatient social worker for many years and that helped prepare me tremendously for mobile emergency work, because I do extremely well with the inpatient qualification and still have a very firm sense of whether someone needs to be admitted or not. It’s really sad and frustrating hearing you talk about the negative experience you had in inpatient. I’m remembering now the burden of tasks that were put upon the inpatient staff. And I remember administration interfering with giving the patients the attention they really needed.

One psychiatrist I worked with explained what inpatient has become – it’s become like factory work. There’s no psychotherapy, and not enough time for staff to talk with patients to really get to know them. It’s extremely fast-paced, there’s not enough time to fully do what needs to get done. Too often they’re prematurely discharged.

Katie: When they’re admitted do they know how many days they’ll stay right off the bat?

Lynn: No, it’s taken on a day-to-day basis and usually they’re not aware of the discharge timing. Sometimes it’s 24 hours. It was impossible to give patients a lot of notice that they were getting discharged. Part of the reason is that I had no way of predicting when outpatient providers would return my calls. I had to call them to schedule follow up appointments and patients weren’t allowed to leave without aftercare set up. So the psychiatrist would be like “Joe cannot be discharged without a partial program.” Then I would scramble to call the partial to complete a referral and would have to wait for the partial to get back to me. In the meantime the insurance is down our throats to get them quickly out. It was impossible to give them any notification of when they’d get out.

Katie: And then if the patient acts out again, does that dictate or change anyone’s mind if they’re acting out even more?

Lynn: Discharges were cancelled sometimes, new info arose or a worsening of symptoms, that happens.

The metaphor “factory work” means: no time to fully get to know them and talk to them. With an ideal inpatient course like it was in the olden days before managed care, there was enough time to thoroughly get patients’ input, enough time to make sure medications were fully adjusted, and that there was enough time to wait for symptoms to decline.

Katie: It’s like the system is broke down. Things seem so rushed – that’s the breakdown of it, right?

Lynn: Right. Unfortunately, I’ve found a lot of patients, even when the inpatient program grants long-term commitments for up to six months, I’ve never seen a patient stay that long. Even with the court order allowing that long, patients are getting prematurely discharged even when approved to move on to a state hospital. In Massachusetts, typically, the only way to get to a state hospital is through a non-state hospital first. I see patients waiting to be approved for a state hospital but a doctor deciding, “Okay, you’re good enough,” scrapping the plans to go to the state hospital and patients returning. I’ve noticed this is far more likely to occur when the patient is pushing to get discharged home or to the street.

Katie: I remember my hospitalization, the first one at 24, I was voluntarily admitted. If I filled out a form within the first 24 hours there so I could get a court hearing and get determined whether I should stay or go. They honored that a week or 10 days or so later, and I went into that court hearing not ready to go, but thinking I want out. I need to get home. I need to get out of this place, because I didn’t like the place, and they couldn’t prove I needed the care. They ended up letting me go. But not even a week later I was back in there and I think that yes, you want to listen to the patient, but was I really ready to go? I don’t know. It’s hard to say because that place wasn’t the best place to be, but it was the hospital, and I needed to get better. Had they kept me maybe they could have readjusted some meds (I don’t think they would have, I think they were just using me as a guinea pig for some other meds they were trying out), but they could have figured out some others meds. Although, I ended up going back three times.

If the patient is wanting so badly to get out, they’ve gotta prove and there’s gotta be enough evidence, especially when they know in their gut they should be there.

Lynn: It’s my suspicion that professionals are uncomfortable with involuntary inpatient because of civil rights — they’re afraid of violating rights.

Katie: At my inpatient hospital they had the Patient Rights line there in the common area, you could call the number but it didn’t connect.

Lynn: That’s shocking. Wow, but I’m sure it was posted visibly because they were cautious to not violate anyone’s rights. But with the phone number being disconnected, did the staff know?

Katie: I’m pretty sure they knew. I really thought they’d put the posters up to cover their butt, but I’m sure other patients – would have brought it to their attention. I don’t know why I didn’t.

Lynn: With the civil commitment criteria, you were asking about imminent risk and what constitutes Section 12, for how their law is set up. [Other states] allow for an involuntary hold, not just for danger. It allows it if there’s a known history of mental illness with deterioration and a need for treatment that prevents further worsening of symptoms that might result in danger. Similar to Massachusetts, if someone is having difficulty attending to their basic biological needs — like if they are not eating because they have a belief that the neighbors are poisoning their food — that qualifies them. While Massachusetts does not have that, [other states do] have it. It also allows the authorization if the person lacks the capacity to understand the need for treatment and is unable or unwilling to act for treatment. In other words, the outpatient psychiatrist is recommending medicine and the person is refusing and not going to any appointments. With the laws in [other states], the person can get hospitalized.

Katie: So it varies state to state the way they write the laws for each state. If I had a family whose family member was portraying suicidal and homicidal ideations and they had Anosognosia, it would depend on what the state’s laws are. Like, if they’re in their right mind and they refuse to go in, it depends on the state’s laws?

Lynn: Yes.

Katie: Is there a resource or website to find that out?

Lynn: The Treatment Advocacy Center. They’re the best in regards to showing the difference between all the states.

 

For more information about Lynn and her book, visit her website at https://lynnnanos.com/.

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.