Stigma and Antipsychiatry

Stigma toward mental illness embodies the belief that mentally ill people caused their illness. It associates mental illness with shame, infamy, and disgrace. How much stigma toward mental illness exists? It’s difficult to measure. Organizations expected to advocate for the mentally ill population, including the National Alliance on Mental Illness (NAMI) (StigmaFree | NAMI: National Alliance on Mental Illness, bit.ly/2AaGvie.), appear to overemphasize stigma as a problem. They portray it as a massive problem and urgently promote campaigns to eradicate it.

Toward the beginning of my career, I grew to believe that stigma was the greatest barrier to accessing sound mental health treatment. I didn’t realize then that I allowed myself to be influenced by the many campaigns against stigma that were advertised. Is stigma less problematic than what the media and certain organizations make it out to be? Is the extent of the stigma that they claim a myth? Although stigma associated with mental illness exists, it is apparently not the greatest barrier to accessing treatment.

The Recovery Learning Communities (RLC) are groups, largely dominated by peer specialists, throughout Massachusetts that endorse the belief that signs of psychosis are normal. Besides running frivolous reiki groups, they regularly lead groups for their members titled “Hearing Voices.” They advertise that “Hearing Voices groups do not pathologize the experience of hearing voices or experiencing other altered/extreme states. Instead, they ask “What does the experience mean to you?”" (“Western Mass RLC | Healing and Recovery Through Peer Support.” Calendar, Western Mass Recovery Learning Community, 8 Nov. 2017, bit.ly/2yFc5Fc.) To pathologize a human experience means to view it as abnormal or dysfunctional. Hearing voices that are not there is certainly not normal. Science proves this. If impressionable people aged in their early twenties experience auditory hallucinations that involve commands to kill themselves or others for the first time and attend these groups, the chances that they will seek out appropriate treatment are reduced when they learn that nothing abnormal is going on. For months in a row in 2017, Western Mass Recovery Learning Community has advertised their seminars, titled Coming Off Psych Drugs, that have taught and encouraged people to stop taking their prescribed psychiatric medication (Davidow, Sera. “Western Mass RLC | Healing and Recovery Through Peer Support.” Coming Off Psych Drugs, Western Mass Recovery Learning Community, bit.ly/2vfutCo.).

When they do not deny the existence of mental illness, RLC minimizes it. Minimizing mental illness is not far off from believing that it doesn’t exist. If prospective followers of the anti-psychiatry camp are not persuaded to believe that no mental illness exists, they might be influenced to minimize mental illness, which contributes to stigma.

The government allows the belief that mental illness does not exist to infiltrate them. Massachusetts’ Department of Mental Health funds RLC (United States. Executive Office of Health and Human Services. Department of Mental Health. Search Results. Commonwealth of Massachusetts, 2017. bit.ly/2yFDQNW.). NAMI's Massachusetts chapter promotes RLC (“PEER SUPPORT RESOURCES.” Peer Support Resources | NAMI Massachusetts, National Alliance on Mental Illness, bit.ly/2iD6wMt.).

Dangerously Unaware

When I started working on an inpatient psychiatric unit as a social work intern for the New York state's Office of Mental Health in 1996, my supervisor told me, "No one here is mentally ill." She was never part of the anti-psychiatry group who believe that mental illness doesn't exist. By stating this, she meant that many of these patients didn't believe that they were ill.

Psychiatric emergency services work can be akin to watching a train wreck without any ability to prevent the wreck from happening. When will the next tragedy involving serious injury or loss of life due to untreated serious mental illness occur? Governments are reactive.

The severe shortage of inpatient psychiatric beds along with overly restrictive inpatient commitment criteria often result in only the sickest of the sick getting admitted to inpatient units. For people with psychosis who lack awareness of being psychotic, brain deterioration often occurs long before sufficient psychiatric treatment is obtained. Early psychosis programs are completely voluntary, thus marginalize those who refuse to engage in treatment because they don't believe that they are ill.

I go to a psychotic woman's apartment with an outpatient worker because she stopped eating. She stopped eating because of her belief that people are poisoning her food. Because she believes that poisonous gas is coming out of her heating vents, she covers these. Because she believes that poisonous gas is coming out of her faucets, she keeps the water running continuously. She believes that running the water blocks the gas. As we are standing in water inches deep, she tells me that she is not mentally ill. Therefore, from her perspective there's no need to take any medication. The police are called and an ambulance transports her to the hospital emergency department. The emergency medical doctor calls and tells me that because she is well groomed, speaking clearly, not suicidal, and not homicidal, she is being discharged back to her home. Everything I report to them is disregarded. I'm just a social worker. Would she be moved on to inpatient if I am a psychiatrist or medical director of an agency? Would she be moved on to inpatient if she has a family member to advocate for her? Weeks later, she is evicted from her apartment with nowhere to sleep except for the streets.

A psychotic man got discharged from Bridgewater state "hospital," really managed by the Department of Correction, earlier that week. He was there because he was eating his feces and cutting himself to remove what he believed was the devil from his body while incarcerated. He yells out his fears of the devil when I evaluate him at the state-funded respite unit. He tells me that he got sentenced to prison because he pointed a loaded gun toward a stranger. I inquire about what made him do this. He says that the devil told him to do it. He doesn't believe that he is mentally ill.

Emergency medical doctors are more likely to discharge to the streets a dangerous patient who is not wanting any treatment, than a dangerous patient who is wanting treatment. They are more likely to move on to inpatient the malingerer who doesn't need treatment, than a psychotic patient who can "pull it together," and cover up symptoms. 

One Source. One Organ.

One of the most challenging cases I ever managed involved sending a patient with antisocial personality disorder to the hospital emergency department involuntarily because he was actively homicidal with an intention, a plan, and a means to kill a targeted peer in the homeless shelter. I could barely identify any other mental abnormality in his clinical presentation. In making the decision to authorize his involuntary transport to the hospital, I used past knowledge, weighed various options and probable outcomes, and reflected on how to promote the safety of all involved. 

Within a couple of hours later, I was challenged by the hospital emergency medical doctor there, who told me that antisocial personality disorder was not enough of a mental illness to warrant any treatment. This doctor then discharged him to the homeless shelter. Personality disorders are considered minor mental disorders, deemed not serious by official regulatory and authoritative standards. So was I expected to send him off to the homeless shelter to kill this peer?

Toward the end of February of this year, I wrote a blog here about the importance of language when referring to recipients of psychiatric treatment services. I argued that using terms besides "patients" when referring to them gives “psychiatry a pseudo-scientific appearance and undermines positive progress.” I went on with “For decades, psychiatry has had a reputation in the medical community as being less than medical, or even unworthy of respect in some instances. Psychiatry and its strides, albeit slower to come by than other medical disciplines, does not deserve a pseudo-scientific reputation.”

Then I came across a publication by the National Alliance on Mental Illness (NAMI), whereby they educate the public about mental illness in a section titled “Mental Health Conditions.” As I saw the many instances in which they use the word “condition,” I thought about how mental illness should not be referred to as a “condition.” Many advocates for the seriously mentally ill population oppose NAMI’s use of the word “condition” because it softens the illness. I agree that the term “illness” appears stronger than “condition,” and thus more indicative of pathology than “condition.” Describing mental illness as a “disease” is even better.

According to a dictionary, “A medical problem or illness can be referred to as a condition.” Did NAMI get it right? Or, did this dictionary get it wrong?

More relevant definitions: 

Mental = pertaining to the mind.

Mind = capacity to feel, think, perceive, and reason.

The literal definition of “psychology” and “psychiatry” is the study of the soul, rooted in the Greek word for “soul,” that is, “psi-chi.”

Soul = feelings, thoughts, behaviors that are typically considered as separate from the physical body. Some religions view this as immortal.

Psychiatry and neurology separated because mental disorders could not be attributed to any physical evidence. Hence neurology took over the study of pathology that was tangible, while psychiatry studied abnormalities that could not be seen. Despite the fact that the ability to feel, think, perceive and reason originates in the brain, many dictionaries still define “mental” as unseen material.

Indeed using the term “mental illness” softens and minimizes the seriousness of brain abnormality. With a bit of guilt, I will consistently use the terms “mental illness” and “mental health” throughout my book. I apologize for this. The reason for sticking to these terms is simple. These terms are so deeply ingrained into the fabric of my professional work and its surrounding field, that not using these terms would draw less of an audience. 

Technology has advanced to the point where schizophrenia, commonly known as a “mental illness,” is physically evident in magnetic scans of the brain. Even features of antisocial personality disorder, such as lack of empathy, are physically evident in the brain. I believe that psychiatry and neurology should merge and become one entire discipline. This would lessen or completely alleviate stigma toward "mental" illness.

Labor of Love

The most common question I get these days is, "When do you think your book will be published?" I have surpassed the halfway mark, and expect to have the first round of professional editing done by May of 2018. This is my first experience with writing a book. I have no past professional writing experience. I've never written an article for a newspaper, journal, or magazine. I've never blogged before these blogs. Deciding to write a book came about suddenly and unexpectedly.

After reading countless scholarly articles and non-fiction books relating to psychology and psychiatry as a hobby, I applied last year to a Doctorate of Psychology program in Massachusetts. My goal was to become a forensic psychologist. After the "enjoyment" (yes, that's sarcastic) of relearning algebra and geometry in preparation for the Graduate Record Examinations, I got as far as the interview. Then, I got rejected.

To the relief of many advocates for the population with serious mental illness, including myself, the federal 21st Century Cures Act passed toward the end of 2016. This monumental law restructures the Substance Abuse and Mental Health Services Administration, and vastly promotes Assisted Outpatient Treatment, along with many other great provisions that are way beyond the scope of this post. I will go into great detail about Assisted Outpatient Treatment in my book. At a glance, this helps a subset of the population with serious mental illness who are not adhering to their recommended outpatient treatment plans. It involves court ordered adherence to outpatient treatment plans, without forcing medication upon anyone. Although the 21st Century Cures Act helps to normalize Assisted Outpatient Treatment and alleviate its controversy, Massachusetts is way behind the times. Refusing to embrace the massive research supporting its effectiveness, it is one of only four states in the United States that doesn't have a law supporting this life-saving treatment.

I realized that five full-time years of further graduate school would have been extraordinarily lengthy and unnecessary, considering the extent of professional experience that I have. Meanwhile, I was struggling to shake off the sense that something was missing within me professionally. We completed the advocacy work that supported the 21st Century Cures Act. Rather than finding another television series to follow, I completed an online writing course. I researched the difference between traditional publishing and self-publishing. I purchased writing software. I learned how to cite research, which was also "enjoyable." I began researching marketing techniques for books.

I've never wanted to become an administrator because of how much I've liked clinical work. But with this, it's nearly impossible to change the mental health system from within my place of employment. Writing a book about my professional experience satisfies my desire to influence change beyond my place of employment. With every session involving work on my book, this void gradually lessens. It's a labor of love. 

Opposition

July 17th, 2017 - 

I arrive at the Boston State House in the morning with two copies of my prepared testimony in hand. One to submit. The other to read aloud.  

I expect there will be lots of waiting while hearing other testimonies since I testified on the same issue in 2013. As I wait, I hear mostly opposition to the Bill. They call themselves "survivors with lived experience." Instead of identifying mental illness as pathology originating from the brain, they berate psychiatrists for labeling people with psychiatric diagnoses. Instead of referring to auditory hallucinations as being a sign of mental illness, they promote the notion that hearing voices not there is simply an extreme state of altered reality (like "alternative facts"). Instead of indicating that psychosis is brain-based, or that no one knows the cause of schizophrenia, one person who testifies expresses her belief that trauma caused her to become psychotic. Instead of pointing to the limitations of the Rogers authorization (enabling administering of medications forcibly) in the community, another person testifying says that the "Rogers monitor is already forced outpatient." Another one testifies that "forced medication is expensive and addictive." Instead of promoting the spread of respite programs that at least administer medications to very ill people (many of whom would otherwise not take these on their own), they request the creation of more peer run respites programs. Who are these people? To be a peer specialist, one must only have experience with being diagnosed with mental illness, or have been traumatized in some way, or have experienced what they refer to as "an extreme state." They encourage people with mental illness to stop taking their medications.* Sprinkles of the belief that mental illness doesn't exist runs amok throughout their teachings. 

The state government financially funds this group (including Reiki which has absolutely no scientific evidence showing it to be effective).** Sad, but true. 

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My testimony: 

My name is Lynn Nanos. I am a Licensed Independent Clinical Social Worker with over 16 years of professional psychiatric inpatient and emergency experience in Massachusetts. I'm currently in emergency work. We shouldn't wait for the next tragedy due to lack of Assisted Outpatient Treatment (AOT). I have witnessed many cases in which people with psychosis have mentally deteriorated to such a deficient level that people have been harmed already. Allowing people with psychosis the right to further deteriorate in functioning is not liberating to anyone. Securing mental health treatment for someone who clearly needs this is not a violation of their rights.

Many of the people with psychosis whom I've professionally helped have had no awareness of their mental illnesses, which is called anosognosia. The majority of people with delusions whom I've evaluated have had anosogosia. Anosognosia is not willful. It involves abnormalities in the frontal and parietal lobes of the brain. All of the following cases involved anosognosia pertaining to psychosis.

A man with psychosis stopped complying with his antipsychotic medications immediately following his discharge from the inpatient unit I worked on. Police officers found that he jumped from the Tobin Bridge to his death within a month following discharge. He had been repeatedly admitted to this inpatient unit well over fifteen times during my years there.

A patient on my inpatient caseload who was paranoid delusional was refusing to accept medications. Shortly after getting discharged he killed his mother.

Between emergency evaluations, a man with psychosis who was not complying with his antipsychotic medications jumped off from a high rooftop to his death.

Police brought into my office a man who was yelling bizarre things on the streets. He was not able to provide a next of kin. He was planning to take the next bus to Washington DC because someone was ordering him to participate in the next presidential campaign. He was paranoid and explained that he's been ordered to kill anyone who tries to prevent him from getting on the next bus.

A person with psychosis and anosognosia cannot understand that treatment is needed. Appropriately timed treatment is more cost effective than lack of treatment. With AOT, admissions to inpatient units are more likely to be timely because its recipients have already been supervised by the outpatient system.

Outside of locked inpatient units, Rogers Monitors are meaningless and invisible. It's impossible to restrain and forcibly administer medications to an adult outside of a secured setting. Except for possibly secretly mixing medications in food, the only places where Rogers authorization have been implemented and enforced are locked inpatient units.

Many people with psychosis who refuse to voluntarily seek help end up incarcerated, which is more expensive than community-based treatment. AOT reduces the chances of arrests, incarcerations, hospitalizations, violence, and homelessness. For your review, I attached to this testimony evidence of the financial, and more importantly, the humane benefits to the majority of states in the United States, that have enacted AOT.

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*Iserman, Mitzi. “Western Mass RLC | Healing and Recovery Through Peer Support.” Coming Off Psych Drugs, Western Mass Recovery Learning Community, 28 July 2017, bit.ly/2vfutCo. 

**United States, Executive Office of Health & Human Services. Department of Mental Health. Recovery Learning Communities. Commonwealth of Massachusetts, 2010. bit.ly/2uGyRcd; “Recovery Learning Communities (RLCs).” Transformation-Center.org, Transformation Center, bit.ly/2u5TESW.

Inspired by Books

Are you looking for a superb book to read? 

I led a non-fiction book club for several years. This group met together at a cafe on a monthly basis and we read one book per month. My interest in psychiatry does not end at my place of employment. The following books inspired me to write my own book (in no particular order). 

• The Psychopath Whisperer: The Science of Those Without Conscience, by Kent A. Kiehl
• On Combat: The Psychology and Physiology of Deadly Combat in War and in Peace, by Dave Grossman, Loren W. Christensen, and Gavin de Becker
• Crazy: A Father's Search Through America's Mental Health Madness, by Pete Earley
• The State Boys Rebellion, by Michael D'Antonio
• Emptying Beds: The Work of an Emergency Psychiatric Unit, by Lorna A. Rhodes
• The Man Who Mistook His Wife for a Hat and Other Clinical Tales, by Oliver Sacks
• Treating the Poor: A Personal Sojourn Through the Rise and Fall Of Community Mental Health, by Matthew P. Dumont
• P.C., M.D.: How Political Correctness Is Corrupting Medicine, by Sally L. Satel
• The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens, by E. Fuller Torrey
• Weekends at Bellevue: Nine Years on the Night Shift at the Psych E.R., by Julie Holland
• After Her Brain Broke: Helping My Daughter Recover Her Sanity, by Susan Inman
• Brain on Fire: My Month of Madness, by Susannah Cahalan
• Total Eclipse of the Mind, by Vicki McDuffie Ferrara
• American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, by E. Fuller Torrey
• Shrinks: The Untold Story of Psychiatry, by Jeffrey A. Lieberman and Ogi Ogas
• A Mother's Reckoning: Living in the Aftermath of Tragedy, by Sue Klebold
• I am Not Sick I Don't Need Help! How to Help Someone with Mental Illness Accept Treatment, by Xavier Amador with Anna-Lisa Johanson

I am currently reading the excellent book, No One Cares About Crazy People: The Chaos and Heartbreak of Mental Health in America, by Ron Powers. 

I read the Shooting At Sandy Hook Elementary School report compiled by The Office Of The Child Advocate of the State of Connecticut. The invigorating debate with friends about the relationship between the mental health system and Adam Lanza's mental state that followed this contributed to my developing new insights. 

If you liked any of these books, I believe there's a substantial chance you'd like mine too. 

Motivation to Help

As far back as I can remember, I've always been fascinated with extreme physical and mental states. The Guinness World Records was one of my favorite television shows as a child. I own four books that were published by the Guinness World Records. I watched every television episode of Taboo that premiered in 2002 on the National Geographic Channel. I enjoy watching videos of extreme sports, such as wing suit flying and free solo climbing.

Psychosis, especially untreated, can be considered an extreme state of mental dysfunction. Psychosis is a loss of connection with reality and a core feature of schizophrenia. Helping patients with psychosis, with or without mood instability, is invigorating. In my experience, whenever patients with psychosis ask me to help them improve the quality of their lives, they're usually genuine. Whenever they present to emergency services reluctantly or involuntarily, their lack of insight into psychosis is startling. Among the countless patients with delusions, medicated or unmedicated, whom I've interviewed, seeing a patient who has insight into being delusional is rare. In fact, I am only able to recall one such case. I'm surprised it's not part of the DSM-5 criteria. Psychiatrists and psychologists advocated for the addition of this in the development of DSM-5 to no avail.

I have no problem taking a patient-directed treatment planning approach with a patient who is high functioning and well enough to understand her or his mental illness and need for treatment. Logically, this method is deficient for other patients. When I am limited in the ability to help patients with schizophrenia because of either overly restrictive law or the absence of law, this motivates me to act abundantly on their behalf.

Our broken system sparks outrage. The greatest expression of passion for a subject matter is teaching it to others and asking for legislative reform.

To read the petition and letter to the National Alliance on Mental Illness (NAMI), attached to a video approximately ten minutes long, that I helped create with other advocates, please click on the following link:
https://www.change.org/p/mary-gilberti-and-nami-board-of-directors-join-families-advocates-of-the-4-in-shattering-silence-about-serious-mental-illness?recruiter=26862745&utm_source=share_petition&utm_medium=facebook&utm_campaign=share_for_starters_page&utm_term=des-lg-no_src-no_msg

To get a sense of NAMI's response to this, as indicated in the second letter that I helped create, please click on the following link:
https://www.change.org/p/mary-gilberti-and-nami-board-of-directors-join-families-advocates-of-the-4-in-shattering-silence-about-serious-mental-illness/u/19149392?recruiter=26862745&utm_source=share_update&utm_medium=facebook&utm_campaign=facebook_link

Minority or Marginalized?

I've read an extraordinary number of scholarly articles and books about mental health, both clinical and public policy oriented. There exists a tremendous quantity of published written material about children, substance abuse, trauma, recovery, how to relax and meditate, and cultural diversity. These are important issues, and certainly are useful to many professionals and patients. In spite of the abundance of these publications, there exist the following facts that I cannot ignore.

• Severe mental illness often strikes in early adulthood. Suicide is more common among older adults. 
• Substance abuse covers up signs of severe mental illness.
• Trauma does not cause schizophrenia. Trauma does not cause bipolar disorder. Trauma does not cause bipolar disorder with psychotic features. Trauma does not cause schizoaffective disorder. Trauma does not cause depression with psychotic features. 
• Some people never recover from mental illness. Find fifteen articles about mental health at random. Count how many times the word "recovery" is used. Then count how many times the word "deterioration" or "relapse" or anything opposing "recovery" is used. How and why did this one word become so popular? 
• Relaxation techniques, including meditation, can be useful. I can't think of anyone not interested in learning about or being reminded of such techniques. These are not appropriate treatments for acute psychosis. 
• Being sensitive to one's culture when psychotherapeutically intervening is important. Schizophrenia exists across all cultures. 

The percentage of higher functioning people with mental illnesses is much higher than the percentage of those with untreated psychosis. Statistics might account for the large quantity of such written publications educating clinicians and the public about these topics. Is there another reason for this?

Praise for Families

Over the last few years, I've had the fortune of acquiring an extensive network of friends who have advocated and still advocate for the severely mentally ill population. The majority of these friends are family members of people with severe mental illnesses. Their horror stories about the barriers faced in accessing care for their sick loved ones are evidence of our broken system. I've seen them fight relentlessly for good mental health treatment.

I recall the many times as an inpatient psychiatric social worker when I couldn't think of anything to say to families besides "My hands are tied. There's nothing further I can do. The doctor is ordering the discharge, not me. I know you're angry." Some of them lashed out angrily at me. I didn't take it personally. I knew they were at a point beyond frustration. Others told me they understood it wasn't my fault that their ill loved ones were getting discharged prematurely again.

This network of new friends also includes Mary Barksdale and Robert "Joe" Bruce (Joe Bruce's story). Mary's son Farron (Farron's story) killed two police officers in Alabama while delusional, unaware of this, and unmedicated. Robert's son William killed his mother, Amy in Maine while delusional, unaware of this, and unmedicated. These and countless other stories inspire me to join their fight. They remind me to stand courageously when I authorize involuntary transfers to hospitals for patients whom I know will be discharged prematurely. In fact, when I think about my patients with psychosis and anosognosia who didn't want help during my inpatient years, I cannot identify one patient who was discharged at the appropriate time.

Borderline Personality Disorder

One of the aspects of my job that I like most is that each case closes very fast, that is, usually in about two to three hours. This means that there's not much opportunity to spend endless amounts of time with patients or family members who are particularly challenging to work with. Many patients among this group have borderline personality disorder.

What is borderline personality disorder? The most common and most outstanding characteristics I've noticed in those patients with this disorder, both as a social worker and in my current role as an emergency clinician are as follows. The following characteristics certainly are not apparent in all patients with borderline personality disorder.

• Many of them make many suicidal gestures (falling between wanting to kill oneself and making a suicide attempt, these include holding a knife close to one's wrist) - the teen who frequently ties clothing around her neck just tight enough to not lose consciousness in the presence of residential staff members. 
• Many of them make suicide attempts with a high chance of rescue, that is, in front of others - the man who hangs himself on a closely supervised inpatient unit. 
• Many of them are not able to identify any new stressor or precipitant that could've contributed to their worsened mental functioning - the young adult who reports being in conflict with her loved ones again. 
• Many of them feel the need to be patients on inpatient units inappropriately, thus can appear desperate to get there - the woman who overdoses on medications in front of me because I'm not willing to meet her demand of inpatient.
• Many of them are passively suicidal without any suicidal plan on a daily basis - the man who reports praying to never wake up again every night at bedtime. 
• Many of them superficially injure themselves intentionally - the woman who's arms are scarred beyond repair resulting in nerve damage. 
• Many of them have no intention to die by suicide - the woman who overdoses on pills forty-five times while passively suicidal, and then dies in the forty-sixth time she does this. 

In Massachusetts, unless a patient is needing a forensic evaluation, such as in determining whether one is criminally responsible for a crime or innocent due to mental illness, a patient needing "long" term inpatient care funded by the state must typically go through a non-state inpatient unit first. A large percentage of the patients on my inpatient caseload (I only worked for non-state units) who were waiting for entry into state-funded inpatient units had borderline personality disorder. This was not a coincidence. Among those patients waiting for this entry, this disorder was the second most common behind illnesses involving psychosis.

As I increasingly realized how serious borderline personality disorder is, it struck me as odd that borderline personality disorder would be this common among those waiting for state-funded inpatient care. They often didn't present with severe signs of mood disorders. They often didn't present with mania. They often were not psychotic. So why were they getting admitted to expectedly the most intensive and most restrictive level of inpatient care possible?

It turns out that they are most dangerous when they've recently increased the potential lethality of their self-injurious behaviors. Their danger involves being most at risk for accidentally killing themselves. I usually do not grant inpatient admission to the patient who is desperately wanting this, but who hasn't engaged in serious self-injury recently and doesn't have a suicidal plan. On the other hand, I ensure that the patient who swallows an object besides food or medication, such as a pen cap, gets transferred to safe confinement.

They can be unpredictable. In emergency services, a patient with borderline personality disorder demands that she be granted an inpatient admission while she is not meeting the criteria for this. Although passively suicidal, she is functioning safely. I try redirecting her to use healthy coping strategies, to no avail. She continues to press for an inpatient admission. She presses for this again until she pours large handfuls of her pills into her mouth, gradually swallowing these in my view. I grant inpatient to her. Even though personality disorders are, by formal definition, less problematic than major mental illnesses, the only mental illness that this patient presents is borderline personality disorder. 

Definition of a Patient

Psychiatry is the only medical specialty that refers to their patients as "survivors," "people with lived experience," "clients," and "consumers."  Are these alternative titles of recipients of mental health treatment really helpful to those with mental illness? The title "survivor" suggests that the recipient of mental health treatment was traumatized from being involved in the mental health system. The title "person with lived experience" suggests that the recipient of mental health treatment was never really mentally ill. Using these titles when referring to recipients of mental health treatment upholds anti-psychiatry groups' belief that mental illness is not real. 

Schizophrenia, severe depression, severe anxiety, and bipolar disorder are real illnesses. Referring to these as "conditions" is disrespectful to psychiatry. Doing this gives psychiatry a pseudo-scientific appearance and undermines positive progress. For decades, psychiatry has had a reputation in the medical community as being less than medical, or even unworthy of respect in some instances. Psychiatry and its strides, albeit slower to come by than other medical disciplines, does not deserve a pseudo-scientific reputation. Organizations dominated by peer specialists (people with a history of emotional distress expected to help patients) rarely refer to recipients of mental health care as “patients." It is not stigmatizing to use language that accurately reflects the relationship between those giving and receiving care.

The titles "client" and "consumer," suggest that recipients of mental health treatment are self-directing their treatment courses. These terms especially isolate those people with mental illness who lack the capacity to direct their treatment plans. When I authorize an involuntary transport to a hospital for someone, I view this person as a patient who is unable to make the appropriate choice about her or his own treatment. 

I will refer to those I help as “patients” in this book to accurately reflect my work. I will do this to give psychiatry, and its recipients of care, the respect that they deserve. 

Mentally Ill? Barely.

I've touched upon the subset of the mentally ill population whom I believe is most impaired. On the opposite end of the spectrum there are those who pretend to be mentally ill. They are referred to as malingerers. They pretend to be sick for secondary gain, that is, hospitalization or a crisis unit stay. Although the most common reason for this is to secure "three hots and a cot" because of homelessness, there are other reasons. For instance, they might have just encountered a drug-deal-gone-wrong and now are in danger of getting killed, thus need to hide out. Or, they might want to build a case to try getting financial benefits from the government.

I want to give attention to this population not because I believe they deserve to occupy my brain space. It should be shouted from the rooftops that they are part of the problem. They occupy precious and limited bed space. They waste health care resources. They waste our tax dollars.

How prevalent is this problem? I haven't found any state specific or nationwide statistics when I searched for this. However, I tracked one hundred cases in a row randomly dispatched to me in order to see what percentage of these were malingering. The results were alarming.

In graduate school at Columbia University, the possibility that patients could lie about their mental states never crossed my mind. When searching for continuing education courses to take in order to maintain my license, I've never come across this topic. When clinicians are educated about how to identify malingering, they are better prepared to show them the exit door rather than enable them.

Underserved Population

The purpose of writing these blog posts is to spread the news about developing this book. These blogs will hint about what will eventually be self-published. In my first post, I began to describe my work as a mobile psychiatric emergency clinician. I will expand on this a bit.

The majority of clinical cases at my current place of employment have involved mentally high-functioning patients. However, I have felt most satisfied when working on the most complicated, most acute cases involving the most mentally impaired patients. My fascination with this population relates to how grossly underserved they are both in the mental health system and the legal system. This subset of the mentally ill population is more impaired than higher functioning subsets. Therefore, it's ironic that they don't appear to be prioritized by many societal entities.

I became alarmed at the extremely high rates of readmissions to the inpatient psychiatric units that I worked on. While emergency work has involved observing patients functioning outside of hospitals for many years, this has sometimes felt like long-term care because of the astronomically high rate of patients returning to the emergency setting.

Background

If you don't professionally interact with the mental health care system or don't have a loved one with serious mental illness, you probably don't think about this population that often. If you or someone you love was impacted by tragedy due to untreated mental illness, you'll more likely understand what I'll be writing about. I'm not referring to people who have their anxiety or depression well under control. I'm more concerned about people who are at risk for seriously harming others relating to psychosis. Unmanaged psychosis involving no medication is a risk factor for violence against others. Public safety is jeopardized when psychosis goes untreated. Despite having more than 15 years of psychiatric experience as a Master's level clinician, I didn't learn this until just about five years ago. And this was accidental. Even before this accident, I gradually realized there was a common theme among those cases involving the most psychosis. Many of these patients lacked awareness of being psychotic, especially in regards to delusions. This is referred to as anosognosia.

I'm just as concerned about people who are not able to meet ordinary demands of life due to severe mood instability or psychosis. From "Being Mortal: Medicine and What Matters in the End," by Atul Gawande: "If you cannot, without assistance, use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk...then you lack the capacity for basic physical independence. If you cannot shop for yourself, prepare your own food, maintain your housekeeping, do your laundry, manage your medications, make phone calls, travel on your own, and handle your finances...then you lack the capacity to live safely on your own." Psychosis can interfere with one's ability to perform these basic tasks, often resulting in repeated evictions from independent apartments. Because they often lack awareness of being psychotic, their chief complaint when presenting to psychiatric emergency services is that they are homeless, not that they are psychotic.

I began my career in psychiatry as an inpatient psychiatric social worker. There, I grew in appreciating the interdependence between clinical assessments and making referrals to outpatient treatment providers, using many resources within myself and the environment. As a social worker, I was most interested in inpatient psychiatric units, but eventually left this type of setting because I wasn't feeling clinically challenged enough. Particularly as an inpatient social worker, I learned about the hierarchy of healthcare disciplines since the ultimate clinical decision-makers in these units were the doctors. However, I often gained credibility, built trust, and influenced them when it mattered most.

As a crisis clinician, I've developed my ability to think critically and make appropriate decisions. Mobile psychiatric work is well suited for those who have a low tolerance for boredom. I've evaluated patients in their personal homes, state residential programs, day treatment programs, rest homes, police stations, sidewalk benches, homeless shelters, doctors' outpatient offices, psychotherapists' offices, respite units, city hall, holding cells of police stations, inpatient medical units, and hospital emergency departments.

Determining whether or not patients are presenting a danger to themselves or others is one of the core roles of a psychiatric emergency clinician. Massachusetts legislators granted me the privilege of authorizing and implementing involuntary transports to hospitals toward the end of 2010. This is certainly not the only role of a psychiatric emergency clinician. Exploring precipitants to crises leads to determining what type of referrals, if any, are needed. Referrals are often made to residential programs, Community Crisis Stabilization units, Partial Hospitalization Programs, acute substance dependence units, outpatient psychopharmacology and psychotherapy, or inpatient hospitalization units.

In upcoming months, I will share more with you about the development of my book. Meanwhile, I hope you enjoyed learning about my background as it relates to this journey.