Lynn Nanos’ book Breakdown paints a bleak picture of the mental health system. Specifically, the book is based on her work in the state of Massachusetts as an emergency psychiatric social worker or clinician working with ‘patients’ (Nanos, Breakdown) with extreme psychiatric diagnoses, i.e., psychosis or schizophrenia.
In the book’s introduction, Lynn states as clear as day, the population she has worked with the most during her tenure as an emergency clinician are also, in fact, the most problematic. She makes an argument for changing the mental health system in her state. In doing so, Lynn identities long-standing issues of access to treatment and the lack of parity between medical and psychiatric care.
The book makes these flawed aspects of the system visible to the reader when it comes to how insurance companies operate in the US, along with other issues of hierarchy within the medical profession, and its impact on patient care and the shortage of psychiatrists in the country.
This book is dedicated to patients who have lost capacity. Lynn does not conceal her interest in working with the most impaired patients. The book features cases with patients experiencing severe psychosis, complex fixed delusional systems, aggressive behaviours, and other complex symptoms impacting her patients lives – necessitating their need for inpatient care because they have lost capacity and are at risk of serious imminent harm to themselves or others. While Lynn has no one speciality or specialisation as an emergency clinician, her training and job responsibilities require her to have a broad skill set and compel her to work with diagnoses across the spectrum.
However, disorders like anxiety, depression, and other diagnoses with less complex symptoms are left absent from this book. Lynn indicates many people, in her experience, with these diagnoses are ‘higher functioning’ or at least, have a greater potential to be better advocates for themselves and be more adherent to their treatment.
Research on the correlation between diagnosis and adherence continues to be limited and making such a claim may be problematic, as many patients who retain full capacity may also be poor advocates.
Lynn suggests her view of the system is narrow given her experiences as an emergency clinician, working with the most extreme and troublesome cases across multiple systems, intersecting the provision of mental health treatment. The book purpose and intent is to raise awareness of the defects inhibiting patients receiving adequate care, specifically in-patient treatment through conversion of their rights to involuntary status.
Lynn makes it quite clear, these are the patients that have lost all capacity and require involuntary in-patient treatment. The goal, she states, is to empower the legislature to make the necessary changes across systems and to provide ‘comfort and validation’ to family and friends of severely mentally ill patients.
Mental health treatment, social work, psychology, and the allied fields are rich with acronyms. This book references many of them, several specific to the state of Massachusetts. However, any clinician will be able to decipher the more specific references to programmes and liken them to larger levels of care. In this sense, the case vignettes are accessible, well written, dramatic, vivid, and at times, extremely disturbing for those who do not work with complex traumas and forensic cases.
Each vignette raises profound realities of the limits of the system in Massachusetts and states with similar laws surrounding mental health treatment, and the conversion of the rights of patients from voluntary to involuntary status to ensure their safety and the welfare of others in the community.
In no uncertain terms, the book takes a hard-line stance on the need for what so many refer to as forced treatment. Lynn does not negotiate a few complexities which are left conspicuously absent from the text. She indicates such cases as substance abuse or illicit drug use, as well as the children’s mental health system, are not included in the case examples. Given the diagnostic problems generally associated with working with drug abusers, concurring disorders, and working with children, vignettes including these cases are not included in the book.
Given the high number of dual diagnoses, MICA (Mentally Ill and Chemically Addicted) or co-occurring disorders among patients suffering from severe psychosis, this book offers little diagnostic advice and direction to clinicians seeking information on how to treat or even manage these disorders on a systems or clinical level. The book also doesn’t evaluate the aetiology of her patients’ disorders, which is less problematic given this isn’t a clinical priority in the provision of care and/or treatment of people with severe psychosis with an emergent need for clinical intervention.
Ultimately, Breakdown achieves what it sets out to accomplish in the book. Lynn Nanos cites case examples of systematic failures in which patients were clearly a danger to themselves or others and their safety was in jeopardy if they were not provided emergency in-patient treatment, albeit involuntary.
At the root of it, these case examples, while vivid, and telling of the extreme dysfunction in the system, are extremely black and white, with little grey area for clinical interpretation in terms of direction for the provision of patient care and treatment. When it comes to the superabundance of liminal psychosocial contexts related to this population, these cases offer little insight into their treatment or new avenues in how to proceed with negotiating the system for their rights and care.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
