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.