Psychiatric Treatment Culture: The Effects of Losing Hope

I’m talking with Lynn Nanos, a social worker specialized in evaluating serious mental illness. Lynn has worked in emergency care, including in-home evaluations, for over ten years, and recently she wrote Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry. We’ve had two great conversations about why it’s so difficult to get help for someone with severe mental illness, and why the well-known MacArthur Foundation’s study on mental illness and violence is flawed and inaccurate. But Lynn and I also shared some observations of the psychiatric treatment culture…

Ruth: When I was looking at search results for “mental illness and violence,” I found something really strange. A 2015 paper spelled out at length why there’s no link between mental illness and violence, but for some reason, I checked one of its footnotes and discovered that the paper it cited actually said the opposite! In fact, this other 2008 paper broke down violent schizophrenics into three groups and suggested different approaches for treating each of them. It was entirely opposed to the first paper but they ignored its findings, apart from this one trivial footnote. That second author must have been pretty frustrated to find her work roped into supporting what she opposed! What’s going on here? Why is only one answer, “there is no link between violence and mental illness,” seemingly allowed?

Lynn: The mental health industry is dominated by the mantra: “Most people with mental illness are no more violent than the general population.” Emphasizing this mantra while downplaying or denying the link feeds a culture without treatment for those who are profoundly ill.

Ruth: That matches my experiences with my son. It was really disorienting to come into it as a mother and find a sort of subculture that had its customs and proverbs. One of the proverbs was “It’s not illegal to be delusional.” Three or four people told me this, and they were technically correct. But what did illegality have to do with it? I didn’t want Levi arrested, I wanted his disease process stopped. At the time, he was too delusional to believe their diagnosis, and the professionals said he had a right not to take medicine. But I felt like they had the power to do things that they chose not to do, though I may not have fully understood their options. For sure, we weren’t on the same page.

Lynn: The culture teaches well-meaning clinicians not to issue involuntary holds where necessary, for fear of drawing the connection between mental illness and violence. It accepts arresting people for violence on inpatient units when the violence was caused by mental illness. And it enables inpatient units to discriminate against those who are violent by refusing to accept them for admission despite that mental illness caused the violence.

Ruth: Hold on, people are held inpatient because they showed “clear and present danger,” but then they get arrested? You have got to be kidding. If violence is the reason they’re admitted, the hospital should be prepared for it!

Lynn: It’s outrageous. Imagine being admitted to inpatient medicine because of unstable blood pressure and getting arrested for this.

Ruth: And you also said, if I got this right, that while families are told they can only press for involuntary inpatient stays due to “clear and present danger,” some hospitals are reluctant or unwilling to admit their loved ones? The family is thinking “well at last they’ll have to take him and he’ll be safe, and we’ll be safe,” but the hospital is thinking, “but we won’t be safe”?

Lynn: Yes, pretty much. By law, all hospitals are equipped to manage violence caused by mental illness. Yet whether they want to is another story. This is where discrimination comes in. The use of chemical and mechanical restraints burdens the hospital and staff don’t want to get hurt.

Ruth: You’ve made it clear that in Breakdown, you’re really going out on a limb. While some in your profession, or in psychiatry, totally agree with you, still you’re speaking against the mainstream opinion. That’s a tough decision to come to. How did you get there?

Lynn: I was uncomfortable and baffled when I first learned about the true link with violence, because I had been influenced by administrators and colleagues to believe there is no substantial link. My entry into advocacy for the sickest of the sick developed as I searched for articles and books about mental illness. When I encountered publications in which the connection between violence and mental illness was clear, I thought, “I don’t understand how this could be true because leaders in my field have taught me otherwise.” As I learned about Farron Barksdale and William Bruce, who killed because of untreated mental illness, my discomfort evaporated. Breakdown details their tragedies. If I had known about your tragedy at the time of its development, Breakdown would have included a chapter tributing your mother.

Ruth: Thank you…mom would have loved that! My dad’s first grief reaction at the time was that her death was meaningless, but soon he realized how meaningful it was: her death has allowed us to explain these important problems. And mom cared a lot about making the world better.

Lynn: So I’m not alone in finding this clash between mantra and facts, but what professionals do with that discomfort determines whether they grow. Rather than accept the status quo as is, I investigated further and found the evidence that eradicated my discomfort and I began my journey toward writing the book. Breakdown demonstrates an array of evidence that shows there is a link between violence and mental illness, especially illness involving untreated psychosis. It lists countless studies showing that the chance of violence increases with the presence of anosognosia.

Ruth: In our other chat, we talked about how just one study came to dominate and drown out these other studies. There’s really not much said about other studies, like that one I turned up. It’s all MacArthur, MacArthur.

Lynn: Many people believe that it supports the mantra: there is no link. And that’s what counts most. There’s also the influence of the new Diagnostic Manual…

Ruth: Tell me about that.

Lynn: The Diagnostic and Statistical Manual of Mental Disorders (DSM) influences and shapes professionals’ view of what is most important. According to the DSM, it seems like everyone is mentally ill. The latest DSM-5 has everything in it for everyone — from nicotine addiction, to grieving the loss of a loved one, to unspecified anxiety or depression, to insomnia, to difficulty adjusting to stressors. The DSM-5 has pathologized normal phenomena more so than the DSM-4. I believe this is a disturbing step backwards because it reflects the mental health industry’s increasing emphasis on the “worried well” — the people who can usually meet ordinary demands of life despite their depression and anxiety. They are housed, pay their electric and cable television bills, eat daily, engage in social activities, etc.

Ruth: They’re many of the people I know and love, and their problems are real. My problems are real, your problems are real. But I guess the question is, do those real problems amount to “mental illness”? One of my advocate friends suggests that we start using the term “neuropsychiatric illness” to underscore that we’re not talking about distress from life’s wear and tear, we’re talking about something that’s organically part of the body, a medical problem. If we don’t make that distinction, then what?

Lynn: Literally speaking, then the mantra is true. Of course if one counts everyone with “mental illness,” however slight, it is true that the majority of those with mental illness are not violent.

Ruth: We don’t fear people with obsessive compulsive disorder or depression, after all. I think we know by instinct that we fear untreated psychosis, when it’s allowed to go unchecked in public.

Lynn: There’s another side of the mental health system. It is at once small and enormous — small in prevalence, but prone to devastating effects on the public at large. Those with untreated psychosis who lack awareness of being ill are marginalized. Psychosis should be pathologized — because there is nothing normal about it.

Ruth: I think many people who have not had to be close to psychosis truly do not understand how far it is from normal. They fear that if they express an unacceptable political view or get involved in a nasty divorce, someone will accuse them of being “psychotic” and they’ll be “locked up.” They worry that psychiatrists will have no way of realizing that they aren’t “crazy.”

Lynn: Professionals don’t have those concerns; when they misunderstand psychosis, it’s because they’ve been indoctrinated to minimize or deny the link between violence and mental illness. Ironically, professionals are often surrounded by psychotic people — the ones that most people are afraid of — yet I suspect some are more afraid of being politically incorrect. They might fear loss of esteem with colleagues, or even loss of employment.

Ruth: The baseline problem in either case is that we don’t yet have an objective scientific test that can legally prove the difference between normal and psychotic, so it remains a matter of opinion. There are some research initiatives and inventions like this AI/fMRI tool, but they’re not ready for legal diagnostic purposes. I think fears about being wrongly considered “crazy” are why voters usually back the idea of violence as a test for involuntary treatment, reasoning that we should only step in when a strange belief becomes a harmful action. But then, instead of talking about disease and early signs and symptoms, we end up with the same conundrum about violence — and that shapes psychiatry too.

Lynn: Violence and agitation are integral parts of psychiatry. No other medical specialty uses the police, our experts on violence-management, as much as psychiatry does. No other medical specialty uses chemical and mechanical restraints as much as psychiatry does. No other medical specialty uses locked doors in treatment settings as much as psychiatry does. The locked doors of inpatient units remind me that those who are most ill, the sickest of the sick, do not want to be there because they have anosognosia. They do not understand that they are ill, thus cannot accept life-saving treatment voluntarily.

Ruth: I felt that the psychiatric culture had become very hopeless, maybe for all these reasons. They were not able to offer families much hope because they didn’t feel it themselves. State laws in most of the US require psychiatrists, nurses and social workers to sit on their hands until danger is “clear and present,” and it won’t allow them to act sooner. They don’t feel much hope, and it has made their treatment culture kind of depressing and uncreative.

Lynn: Being a psychiatric social worker is akin to watching a train wreck with no ability to prevent it from happening. The unfortunate reality is that there is minimal hope for recovery in many cases. Graduate social work programs teach students to instill hope in their clients/patients. Yet, the system can make it extraordinarily difficult to do this. I encourage family members of sick loved ones to advocate at the state house — because governments change only when pressured.

Ruth: How has Breakdown been received, so far, inside your profession? Have you had much feedback? I know you gave a lecture recently, how did that audience react?

Lynn: Breakdown is controversial, especially in Massachusetts where I live, partly because Assisted Outpatient Treatment (AOT) is not allowed. However, I’ve been surprised by the overall support and acceptance of Breakdown that I’ve received from colleagues. It seems they’ve embraced it because I’ve dared to publicly state what they’ve been thinking all along. I lectured at the National Alliance on Mental Illness in GA. Some members of the audience shared their tragic stories. Others did not know what AOT was, despite that it’s allowed by law in Georgia. There is a lot more work that needs to be done.

Ruth: My state just changed its standards to make AOT more possible. I think the reason advocates like us keep pushing for AOT is that we (at least I) feel that it might really change the treatment culture in ways that are bigger than just its bare bones provisions. 1 + 1 might equal 3, because there’s a human element here — the feeling of helplessness — and how we rationalize and justify the helplessness we feel. It seems like there are more depressing stories than successful endings. Let’s change that balance if we can!

Lynn’s book: Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry

Link to our first article: “Five Reasons Why We Can’t Get Help for Mental Illness: Interview with Lynn Nanos

Link to second article: “Mental Illness and Violence: About that MacArthur Study…