Breaking Down Barriers to Care

Do you have a family member with a severe mental illness? Are you a professional who helps people with serious mental illness? If so, you probably noticed that the mental health system is deeply flawed. I wrote the newly published book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry (available for purchase at all major online stores), to appeal for legislative reform because it's nearly impossible to change the system within the trenches of clinical work.

Breakdown traces key events in the history of the mental health system: factors that contributed to the mass closing of hospitals, the dramatic decline of inpatient lengths of stay, and the narrowing of civil commitment criteria. Detailed case vignettes demonstrate interactions between patients, their families, police officers, and other mental health providers as they navigate a path toward reducing and preventing danger. Yet, the system limits their ability to help, as too many patients end up homeless, jailed, harming themselves, harming others, or even dead.

Overly restrictive inpatient commitment criteria often result in only the sickest of the sick getting admitted to inpatient units. Breakdown compares the civil commitment criteria of Wisconsin and Massachusetts. While Wisconsin considers recent psychiatric deterioration and the need for treatment to prevent further deterioration that could result in danger, Massachusetts does not. In other words, Wisconsin aims to prevent danger while Massachusetts does little to nothing to prevent it. Consequently, patients rapidly cycle to and from both inpatient units and hospital emergency departments, as well as to and from jails and prisons. 

When patients with serious mental illness are not in jail or hospitalized, crisis can occur anywhere. Breakdown shows where patients can be evaluated to determine if they meet inpatient criteria: Lily - who traveled from Maine to Massachusetts because she was ordered by her voice, a spirit called "Crystal," to make the trip - is at an outpatient agency that focuses on homelessness; Antonio - who delivers insects to his neighbors' homes to minimize the effects of poisonous toxins that he says exist in their homes - is at his apartment; Owen - foul-smelling, oddly dressed, barefooted, and unable to stop talking - is in my office; Dante - who repeatedly calls the police with complaints about “someone” who attempted to kill him - is at the police station; Jon – who is suspicious of the FBI - is at a homeless shelter.

Administrative pressure to reduce hospital emergency lengths of stay can result in premature discharges. Without proper treatment, symptoms worsen, and readmission to emergency services is inevitable - if they do not inflict serious injury on themselves, others, or get arrested first. While the inpatient lengths of stay have declined since deinstitutionalization, the readmission rates to inpatient units have increased.[1]

As a result of the combination of limited inpatient beds and inpatient admission units’ refusal to accept some of the most challenging cases, patients languish for weeks in hospital emergency departments before placements become available. Those most prone to violence, most likely to get stuck for months on inpatient, or without health insurance inevitably wait for treatment the longest. Breakdown recommends that these inpatient units be held accountable and face consequences for this type of discrimination.

Meanwhile, patients who fake the need for care are smoothly and swiftly moved to inpatient settings. This population occupies precious and limited bed space and wastes health care resources. Malingerers pretend to be sick for secondary gain, that is, a hospitalization or a crisis unit stay. Although the most common reason for this is to secure Three Hots and a Cot (Chapter 11) because of homelessness, other reasons exist. 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.

Another commonly encountered group in emergency services involves patients with borderline personality disorder. Their danger involves being most at risk for accidentally killing themselves. I usually do not grant inpatient admission to the patient who desperately wants this, but hasn't engaged in severe 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.

For people with psychosis who lack awareness of being psychotic, brain deterioration often occurs long before enough psychiatric treatment is obtained. Even after treatment has been sought, it can be difficult or impossible to alleviate the damage already done. Breakdown closely examines Assisted Outpatient Treatment (AOT) as a means of preventing danger. 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. The evidence in favor of it uniformly shows that it reduces rates of homelessness, incarcerations, violence, poor self-care, and hospitalizations. Yet, Massachusetts, Maryland, and Connecticut are the only states that do not allow AOT, even though the 21st Century Cures Act helped to normalize it and alleviate its controversy.

When I testified in favor of AOT at the Boston State House on July 17th, 2017, most of the opposition came from peer specialists who referred to themselves as "survivors with lived experience." 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." At the hearing, I was stunned at their arguments. Instead of identifying mental illness as pathology originating from the brain, they berated psychiatrists for labeling people with psychiatric diagnoses. Instead of referring to auditory hallucinations as being a sign of mental illness, they promoted the notion that hearing voices not there is simply an extreme state of altered reality. Instead of indicating that psychosis is brain-based, or that no one knows the cause of schizophrenia, one person who testified expressed her belief that trauma caused her to become psychotic. Instead of pointing to the limitations of the Rogers authorization (enabling forcible administration of antipsychotic medication by mental health professionals) in the community, another person testified that the "Rogers monitor is already forced outpatient." Another one said 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 requested that more peer-run respite programs arise. The belief that mental illness doesn't exist runs amok throughout their teachings. Yet, the state government financially has funded this group for years.[2] Breakdown delves into how this group operates and asks the government to discredit them.

The current system didn’t get this way overnight. Flaws stem from deinstitutionalization that began in the 1940s. Civil commitment laws in many states are overly restrictive. Inpatient lengths of stay are too short for those who need this most. There is a shortage of inpatient beds. Malingerers must be shown the exit door. Borderline personality disorder is a serious mental illness that warrants just as much attention as bipolar disorder. Discrimination by inpatient units against the most challenging cases must end. Antipsychiatry has no place in government-funded treatment. AOT is a sound evidence-based tool that is widely underutilized.

The greatest expression of passion for a cause is to educate others about it and request legislative reform. Although most mobile psychiatric emergency cases have involved mentally high-functioning patients, I’ve been most invigorated from helping the most impaired patients, usually suffering from psychosis. They are grossly under-served in both the mental health and legal systems. Breakdown is dedicated to this population. 

[1] Appleby, L., et al. “Length of Inpatient Stay and Recidivism among Patients with Schizophrenia.” Psychiatric Services, vol. 47, no. 9, 1996, pp. 985–990, doi:10.1176/ps.47.9.985; Appleby, L., et al. “Length of Stay and Recidivism in Schizophrenia: a Study of Public Psychiatric Hospital Patients.” American Journal of Psychiatry, vol. 150, no. 1, 1993, pp. 72–76, doi:10.1176/ajp.150.1.72. 

[2] 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, bit.ly/2u5TESW.

Analysis of a Catastrophe

On Wednesday, February 14, 2018, nineteen years old Nikolas Cruz used a semiautomatic rifle to kill seventeen people, mostly teenagers at Marjory Stoneham Douglas High School. Cruz’s violent actions were so beyond the realm of normal behavior that many, including myself, assume that he was mentally ill at the time. Untreated seriously mentally people are more likely to be violent than the general population.

What was the extent of his mental illness? What can legislators do to try to prevent a recurrence? Should they tighten gun control or reduce mental illness? Although Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry will not address the gun control debate, the most thorough examination of mental illness should include it.

In One Source. One Organ posted on October 1, 2017, I wrote: “Even features of antisocial personality disorder, such as lack of empathy, are physically evident in the brain.” After a homicidal man told me about his enjoyment of killing small animals and his lack of remorse for harming others, I authorized his involuntary transfer to the hospital. He had a specific plan, means, and target in mind. He also killed people in the past. Later, the hospital emergency physician released him to a homeless shelter and told me that antisocial personality disorder didn’t rise to the level of inpatient criteria.

As a mobile psychiatric emergency clinician, I decide on a daily basis whether or not to authorize involuntary transfers of mentally ill patients to the hospital. I examine all the information available to me and ask myself if anyone will die if containment is not arranged. If Cruz landed on my caseload, what would I have done?

Let’s suppose that a family member brought to my attention that Cruz cut his arm on Snapchat. What did he intend to do when he cut? How deep into the skin did he go? Where on the body did he cut? Close to a vein or artery? Or between the elbow and wrist? Was he alone when he did this?

The Federal Bureau of Investigation (FBI) reported that someone reported to them that his behavior was erratic. (https://bit.ly/2sKib4C) This alone is not specific enough to warrant commitment.

Snapchat showed that he wanted to buy a gun. (https://bit.ly/2sKib4C) He bought the gun legally.

Well over forty articles all show that Cruz said that demon voices instructed him to kill his peers. To be clear, if this were known before the shooting, he would have qualified for inpatient. It arose after the tragedy. I cannot conclude that he was psychotic because it is too vague. Religious patients told me that God talked to them, or that they should not have listened to the devil just before making poor choices. Cruz did not make this statement to a forensic clinician. He might have been asked this in a leading way. His developmental disability might have interfered with his ability to report information accurately. Young children who do not have the same intellectual capacity as most adults have are certainly not always reliable reporters. He might have intended to say that he chose to act violently. Delusions are associated more with violence than hallucinations are.

Another diagnosis might have been discovered if he was in treatment. He was out of mental health treatment for more than a year, despite professionals recommending that he receive treatment. He was diagnosed with mental illnesses that are not associated with violence - autism, attention-deficit and hyperactivity disorder, and depression. However, the lack of being in treatment becomes alarming when considering the following threats of violence.

His caretaker called 911 stating that he put a gun to his brother’s head and previously put a gun to his mother’s head. (https://bit.ly/2opRHAw)

On January 5, 2018, the FBI was informed that he owned a gun. (https://bit.ly/2sKib4C) This alone was not enough to qualify for inpatient, but when placed in the following context, inpatient criteria was met. Someone called the FBI last month stating that Cruz intended to kill people, perhaps at school. (https://nyti.ms/2ocUTiR) According to the Department of Child and Family Services, he expressed a desire to kill people. (https://bit.ly/2sKib4C)

Cruz threated to harm his peers at school. He was referred for a threat assessment by the school in January 2017. (https://nyti.ms/2ocUTiR) A teacher requested of the administration, social worker(s), and psychologist(s) that they meet with him and his caregivers to assess what mental health services can be recommended or if he needs to be hospitalized. Before getting expelled, he was not permitted to carry a backpack to school because of the threats he made toward other students.

Last year, someone notified the FBI that Cruz posted on YouTube “Im going to be a professional school shooter.” (https://bit.ly/2EGSc3m) An FBI representative said that they could not identify the author. This doesn’t seem accurate to me. Rather than order a psychiatric evaluation, they chose to do nothing.

Public defender Melisa McNeill said that Cruz is remorseful. This alludes to the possibility of serious mental illness. An array of articles point to his killing of small animals. This refers to the possibility of antisocial personality disorder. Stating that mental illness is rarely the cause of mass shootings minimizes the extent of its role.

The system is not sophisticated enough to consistently identify and predict who is most at risk of murdering others. The National Rifle Association spokeswoman Dana Loesch voiced that mentally disturbed people shouldn't be allowed to purchase guns. As long as the mental health system is as dysfunctional as it is, the implementation of this feat would be impossible because persons' potential for imposing violence is not always apparent. Under federal law, people who have been involuntarily committed are not allowed to buy guns. This is not nearly enough to prevent another school massacre. Firstly, commitment standards are overly restrictive in most states, which makes it hard to hospitalize people. Secondly, even if a dangerous person gets involuntarily committed and released, there are so many guns available in the United States that he can easily obtain one illegally.

My personal opinion is that all common civilians should not be allowed to access guns with the capacity (e.g., fast-capacity magazines, bump stocks) to inflict the carnage seen at Virginia Polytechnic college, Sandy Hook elementary school, and Douglas high school. The states and countries with the strictest gun laws have the least deaths from guns. (https://bit.ly/2HKOjs8) Approximately 99 percent of the world does not have anything akin to our second amendment. Antiquated and unnecessary, it is repeatedly used as an excuse for gun violence. Cruz's right to own a gun obliterated the rights of these children. The United States is the only country in the world that encompasses this conversation. It is not needed elsewhere.

When safety concerns are brought to my attention, and the patient denies these, reliability must be questioned. When hints and clues exist, what is not seen must be considered. Dig deeply to unmask the whole story. Trust your instincts. Talk to people who know the patient best.

Evaluate, transfer, discharge. Repeat.

While the inpatient lengths of stay have declined since deinstitutionalization, the readmission rates to inpatient units have increased.* The revolving door in the mental health system refers to the rapid cycling of admissions and discharges to and from both inpatient units and hospital emergency departments, as well as to and from jails and prisons.
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A police officer escorts to my office a twenty-nine years old man, Owen. The officer explains that a psychotherapist's office called the police for assistance to have Owen removed from their agency because he was verbally aggressive and disruptive, refusing to leave. Apparently, he was there attempting to participate in an initial intake appointment to receive therapy and medication.

The hair on his head and face is long and matted. Even though the weather is warm outside, he is wearing three jackets. I look down and notice he's wearing only one shoe.

I cannot understand what he’s trying to convey because he rambles quickly and incoherently. Eventually, he tells me that he was referred to this intake appointment by a hospital emergency department. Besides telling me that he could benefit from some psychotherapy for his mania, he has no other concern and desires no other treatment.

He allows me to call his mom, Martha, so I do. She tells me that Owen has been functioning at the level I see today for the last four years, at which time she's been trying to get him help to no avail. "They keep on discharging him with nothing. They keep telling me he can't be helped unless he wants to be helped. He can go for weeks without sleeping. He has not even a cent to his name! The police usually bring him to the hospital. They call me, I beg them to keep him, but instead, they just let him go. It’s the same thing over and over again. He was diagnosed with bipolar and has been unmedicated for the last four years.” 

Owen is clearly unable to meet the ordinary demands of life. He is unable to attend to his basic biological needs. He is unable to maintain normal relationships. He is unable to communicate normally. I tell his mother about my intention to arrange for his hospitalization. To her relief, she agrees but cautions "He knows what to say to get out. They always believe him."

I try to find Owen with a plan to gauge if he'd be willing to go to the hospital. He is gone. I fax the involuntary authorization, with his mother's address on it, to the police. Hours later after completing an additional case, the police tell me they never found him. 

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A week later, I am walking in the hallway just outside my office, when I happen to see Owen speaking in a loud tone of voice, apparently arguing with a staff member.

"Is this the intake office for the outpatient department?" He still appears disoriented to the situation at hand, as he demands from me socks, shoes, a new apartment, and employment. I tell him that I cannot directly give these materials to him. Believing there is a moderate chance that he'll prematurely elope again from me, I quickly latch on to anything that could persuade him to allow me to interview him. I attempt to reassure him about my intentions to help him, by offering to help him investigate when and where his next outpatient appointment is, or if he even has one scheduled. 

He is more malodorous than he was last week. Following his train of thought is impossible. He is talking fast and excessively. I attempt to interrupt him numerous times to no avail, but he quickly interrupts me at every attempt. He is animated with restless body movements. He asks loudly, "What kind of fucking establishment are you running here? You're a joke," before vehemently listing the many reasons that I should have never been granted a master's degree. 

He mindlessly repeats my verbalizations. As I increasingly write notes, his agitation increases. He demands to read everything I write because of his belief that I'm writing lies about him. I stop writing. In the briefest silence imaginable surrounding his garrulousness, I ask if he hears any voice that may not sound real. He yells, "No!" Seemingly fifteen minutes later, he voicelessly utters words for a couple of seconds.

I offer him water and suggest that we briefly break so that I can consult with colleagues for advice. We agree to part, and he accepts water from me. I ask a colleague to watch him while I write up the involuntary hold out of his view, suspecting that he would likely elope if he sees me writing it. I fax it to the police. Almost whispering to prevent Owen from hearing me, I call the police and ask for their assistance. When I go to check on Owen, he is nowhere in sight.

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A month later, I reassess him. Seeing patients with psychosis cycle through emergency departments repeatedly within months before they are moved on to inpatient units is expected.

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*Appleby, L., et al. “Length of Inpatient Stay and Recidivism among Patients with Schizophrenia.” Psychiatric Services, vol. 47, no. 9, 1996, pp. 985–990, doi:10.1176/ps.47.9.985.; Appleby, L., et al. “Length of Stay and Recidivism in Schizophrenia: a Study of Public Psychiatric Hospital Patients.” American Journal of Psychiatry, vol. 150, no. 1, 1993, pp. 72–76, doi:10.1176/ajp.150.1.72.