What inspired you to write the book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, that got published in October of 2018?
I’m in my 14th year as a mobile emergency psychiatric social worker. 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 underserved in both the mental health and legal systems. Breakdown is dedicated to this population.
I increasingly realized that there is no opportunity to influence legislators to change the system in the clinical setting. I wrote Breakdown to appeal for legislative reform because it’s nearly impossible to change the system from within the trenches of clinical work. Very few people are aware of the population I help and what they struggle with. The greatest expression of passion for a cause is to educate others about it and request legislative reform.
I had done mental health advocacy work on a national scale for years before beginning to work on Breakdown and was very inspired by advocates’ tragic stories. Their stories motivated me to become a better social worker and write Breakdown. Certain high-profile tragedies were at the forefront of my memory because they were especially dramatic and shocking.
What is your main work role?
My main work role is to prevent or decrease danger. For instance, if someone is refusing to eat for days, losing weight because she believes that neighbors are poisoning her food, but doesn’t believe she’s ill and thus is not getting treatment, she needs to be treated on an inpatient unit. My job is to make this happen. I can authorize involuntary transfers of patients to hospitals. If they don’t qualify for inpatient, I can refer them to outpatient treatment programs or give them self-help material.
What do you mean by “mobile”?
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. I see patients at homeless shelters, personal homes, police stations, holding cells of police stations, my office, doctors’ offices, even street sidewalks. I evaluate patients at hospital emergency rooms and inpatient medical units.
- Lily travels 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.
How did you get into this field of work?
I’ve always felt most 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 the government. For instance, it’s a lot easier for someone pretending that she or he is suicidal to get into an inpatient unit, than for someone who is prone to violence because of psychosis.
Breakdown discusses discrimination a lot. A lot of inpatient units, if not all, discriminate against the most challenging cases, and this motivates me to advocate for the them. The fact that those who need the most help seem to be the most neglected is tragically ironic.
How do inpatient units discriminate against those who are most sick?
Inpatient units discriminate by declining to admit patients who are most violent, not wanting treatment, lack health insurance, and who will likely present overly challenging barriers to discharge from inpatient rendering longer than average lengths of stay.
Hospitals might prefer that patients who require restraints be discharged sooner than patients without restraints because the use of restraints burdens hospital resources. If a doctor orders restraints, physical strength and mobility of additional staff members are required to enforce the order safely. Workers are expected to observe the restrained patient closely and continuously. There is the emotional burden of staff and verbal escalation techniques didn’t work. They might have offered choices, set limits, provided empathy to no avail. Patients’ inability to listen is a sign that restraints might be needed. After restraints have been removed, they process the incident by talking with the patient and amongst themselves. Additional documentation requirements for staff. All these tasks take staff away from attending to other patients.
Breakdown shows a study in which restrained patients spend more time hospitalized than non-restrained patients. Certain inpatient units claim having extremely low restraint rates, but it’s likely they’re not accepting the most challenging cases.
How do you propose discrimination be curtailed or eliminated?
As a result of the combination of limited inpatient beds and inpatient admissions units’ refusal to accept some of the most challenging cases, patients languish for weeks in hospital emergency rooms before placements become available. Breakdown recommends that inpatient units that discriminate be held accountable and face consequences. Emergency programs doing bed searches could report to the government and units could be closed if discrimination is not resolved.
How common is it for you to evaluate people who are clearly sick enough to need help, but not sick enough to warrant hospitalization?
It’s very common. Anyone who is completely psychotic needs professional help. But someone can have this level of psychosis with the ability to eat, sleep, clean herself, protect herself from basic harm, pay rent, along with not posing a risk of serious physical harm to anyone. This is the grey area, where they need help, but it legally cannot be forced.
The law doesn’t care that the psychosis will worsen and interfere with the ability to attend to basic needs in the eventual future. Nor does the law care that someone might get killed due to delusion in the eventual future.
If a patient has lost weight in the last couple of weeks because of the belief that aliens are poisoning his food and plans on continuing to starve himself, I can authorize an involuntary hold because risk of danger is imminent. If a patient expresses a plan to physically assault someone else due to delusion, I can authorize an involuntary transfer to the hospital. The law only cares about what is imminent.
Tell me about the revolving door of cycling in and out of hospitals and jails.
Most states have overly restrictive involuntary hold laws. This contributes to patients rapidly cycling to and from both inpatient units and hospital emergency rooms, as well as to and from jails and prisons. 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 don’t inflict serious injury on themselves, others, or get arrested first.
What is one of the tools that can be used to curtail the revolving door?
Approximately half of people with schizophrenia or bipolar lack awareness of their illness, called anosognosia. Psychosis involves the most anosognosia. This results in treatment non-adherence. Anosognosia is the most common reason people don’t adhere to treatment recommendations. For people with psychosis with anosognosia, 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 brain damage already done.
Breakdown makes a sound case in favor of Assisted Outpatient Treatment (AOT), an evidence-based tool that’s widely underutilized. AOT helps a subset of the population with serious mental illness who are not adhering to their recommended outpatient treatment plans. It usually involves court-ordered adherence to outpatient treatment plans. Court order is vastly preferred because of the black robe effect. The black robe effect is the tendency of people to adhere to an order of a judge because of the judge’s power and authority.
The evidence in favor of it uniformly shows that it reduces rates of homelessness, incarcerations, violence, poor self-care, and hospitalizations. All states and Washington DC allow AOT, except for Massachusetts, Maryland, and Connecticut, even though the 21st Century Cures Act of 2016 helped to normalize it and alleviate its controversy.
We hear a lot of calls for the elimination of the IMD exclusion. What is the IMD exclusion and why should it be repealed?
IMD stands for Institutions for Mental Diseases and the IMD exclusion is a law under the Social Security Administration that prohibits the federal government from financially reimbursing Medicaid for inpatient psychiatric facilities with more than sixteen beds for patients aged twenty-one (and in certain circumstances twenty-two) to sixty-four years old.
The IMD Exclusion must be repealed because it is the main reason that inpatient psychiatric hospitals have eliminated so many beds. Number of inpatient beds in the United States has dropped by at least 96 percent since the 1950s, despite an increase in the population.
In the 1950s, state hospitals provided respite and asylum for the mentally ill population. The states primarily funded these hospitals through taxes until the Medicaid program was created in 1965. Apparently, the main motivation behind the IMD Exclusion was to expand treatment outside of hospitals.
The lack of enough inpatient psychiatric beds has shifted the responsibility of housing and asylum of the mentally ill from state hospitals to our jails and prisons.
A lot of advocates complain about how HIPAA interferes with care. What is your solution to this?
If the mental health system in the United States worked properly and if psychosis could be treated easily, the Health Insurance Portability and Accountability Act (HIPAA) would not be as problematic as it is now.
Because the system is very far from working properly and psychosis cannot be treated easily, I offer the following solution, in the meantime. From Breakdown: “When anosognosia and psychosis render a patient unable to make sound judgments involving treatment recommendations, and unable to sign any release of confidentiality document, it warrants an exception to the conventional procedure. If the clinical record already includes the name of a family member or friend, relationship to the patient, and phone number or email address of the person, confidentiality law could allow for two psychiatrists to authorize an exception to confidentiality rules. The team would inform the patient of this override. This type of HIPAA authorization would enable the inpatient treatment team to have contact with the patient’s closest family member or friend, which would enable safe discharge planning.”
What are the most important messages of Breakdown?
The most common reason that approximately half of people with schizophrenia are unable to initiate treatment independently or adhere to treatment is anosognosia. This means they lack awareness of being ill. Anosognosia is a key factor contributing to the need for involuntary treatment.
When schizophrenia goes untreated, the consequences can be deadly. I’ve detailed high profile cases based on media reports and my interviews with family members. These cases have involved people getting killed due to untreated mental illness.
This is bound to make many people uncomfortable for fear of stigmatizing mental illness by suggesting that people with mental illness are violent. Most people with mental illness are not violent. Yet a small subset of the population with untreated serious mental illness, especially involving psychosis, is more violent than the general population. Truth does not enhance stigma.
What new projects are you working on?
Since I traveled to many conferences to promote Breakdown before the COVID pandemic, I’ve taken a bit of a break. I’m still employed full-time as a mobile emergency services social worker. I’ve just recently started an editing business for writers through Upwork. I’m working toward an editing certificate. I’m going to grow that as a side gig, using the accolades of Breakdown, such as the awards it won to help market the business.
Bipolar Bandit (Michelle Clark) 
Now after reading this fantastic interview, I shall try to get a copy of this book!