May 28, 2025 • 27 mins
Lynn Nanos, a mobile psychiatric emergency social worker with 15+ years experience, shares insights on evaluating and helping people with serious mental illness in crisis situations.
Her work bridges the gap between law enforcement and mental healthcare, providing crucial interventions for individuals experiencing psychosis and other mental health emergencies.
• Conducts psychiatric evaluations in various settings including homes, police stations, nursing homes, and even public spaces
• Assesses whether individuals need hospitalization or can be referred to outpatient treatment
• Works with police to divert people from the criminal justice system when possible
• Explains the "revolving door" problem with brief hospital stays leading to recurring crises
• Advocates for Assisted Outpatient Treatment (AOT) to reduce homelessness, hospitalization, and incarceration
• Discusses anosognosia (lack of awareness of illness) affecting up to 97% of untreated schizophrenia patients
• Clarifies that most people with mental illness are not violent and are more likely to be victims
• Highlights the difference between psychosis and borderline personality disorder interventions
• Emphasizes that mental illnesses are brain disorders that shouldn't be stigmatized
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Welcome to why Not Me ?
The World Podcast, hosted byTony Mantor, broadcasting from
Music City, usa, nashville,tennessee.
Join us as our guests tell ustheir stories.
Some will make you laugh, somewill make you cry.
Their stories Some will makeyou laugh, some will make you
(00:30):
cry.
Real life people who willinspire and show that you are
not alone in this world.
Hopefully, you gain moreawareness, acceptance and a
better understanding for autismAround the World.
Hi, I'm Tony Mantor.
(00:53):
Welcome to why Not Me?
The World Humanity OverHandcuffs the Silent Crisis
special event.
Joining us today is Lynn Nanos.
She is an LICSW, she has donethis for most of her life and
she is very passionate abouthelping people with serious
mental illness, especially thoseinvolving psychosis.
She brings a wealth ofexperience from her work on a
(01:17):
mobile crisis unit inMassachusetts.
She's here to share insights oncollaborating with law
enforcement, navigating complexcases and diagnosing a diverse
range of individuals in crisis.
Her expertise offers a uniqueperspective on mental health
intervention and we'reincredibly grateful for her time
(01:37):
and knowledge.
Thanks for coming on.
Speaker 2 (01:40):
I'm glad to be here.
Speaker 1 (01:42):
Yes, it's great to have you on If you could tell us
a little bit about what it isthat you do.
Speaker 2 (01:50):
So I am a mobile psychiatric emergency social
worker in Massachusetts.
I am in 15th year of full-timework and previously I worked for
another emergency servicesagency for two years.
(02:11):
So all in all, that's manyyears of doing mobile crisis
work, in which I assess peoplewho are in crisis and determine
whether they need to behospitalized, and if they don't
need to be hospitalized, I canrefer them to outpatient
treatment programs or give themself-help material.
(02:35):
I'm an LICSW which is LicensedIndependent Clinical Social
Worker, and that gives me theability to authorize involuntary
transfers to the hospital forpeople who are unsafe.
Speaker 1 (02:52):
Do you work with the police alongside them or, lots
of times, do you work withoutthem?
Speaker 2 (02:58):
Some cases involve referrals from police officers
and other cases don't involvethe police, so it really varies.
Speaker 1 (03:06):
So, when you are involved with the police, what's
the criteria for you to workwith them so you can get
everything you need undercontrol and create a better
situation for everyone involved?
Speaker 2 (03:18):
Well, I do a psychiatric evaluation with the
police and I try to divert themaway from the criminal justice
system, from being arrested.
I can authorize involuntaryholds, which in Massachusetts is
called a Section 12.
And if the person in crisis isout of control and uncooperative
(03:45):
and not willing to go to thehospital, the police can help to
, along with me, persuade theperson to agree to
hospitalization.
They use restraint as a lastresort and I typically don't see
people being restrained becausewe can usually persuade them to
agree to the hospitalization,but occasionally they have to be
(04:09):
forcibly restrained.
Speaker 1 (04:11):
So if it does get out of control, where they have to
be restrained and they needmedication, is that done there
or at a different time?
Speaker 2 (04:19):
I don't have anything to do with medication.
Have anything to do withmedication.
The medication occurs at thehospital setting like after
they're transported to thehospital.
Speaker 1 (04:35):
Okay, that makes sense.
So what led you to get intothis business?
It's not your everyday nine tofive job that people think of,
so what drew you to doing thisprofession?
Speaker 2 (04:41):
Well, I've always been most invigorated by helping
the sickest of the sick, thepeople who are least functional.
I really enjoy helping people.
I always found it really, youknow, tragically ironic that the
people who are most sick seemto be the least helped by the
(05:03):
government.
They seem to be the mostunderserved, and this motivates
me to want to help them, and soI've always felt most
comfortable dealing with peoplewho are very sick, with
psychosis usually.
Speaker 1 (05:17):
I think that's great.
So what's your first approach?
When you first come onto thescene?
How do you handle this with theperson that you're going to be
looking at and ultimately tryingto help out?
So what's the first thing thatyou do?
Speaker 2 (05:31):
Well, I begin with telling them that I want to get
to know them a little bit, askthem a few questions to try to
figure out how to best help themout.
And I ask some backgroundquestions.
And then, of course, there arethe safety questions which are
critical.
There are questions involvinghistory of past suicide attempts
(05:53):
, history of hallucinations,whether the person is suicidal
or having any thoughts ofwanting to harm others.
Right now I use my instinct andmy gut a lot, because I've been
doing this work for many years.
I can tell if someone needs tobe hospitalized, usually pretty
(06:16):
quickly.
Sometimes it takes longer thanother times, but I think my
instinct has been well-developedat this point so that I can
determine pretty quickly ifsomeone needs to be
involuntarily transferred to thehospital or voluntarily
hospitalized.
They usually go voluntarily.
(06:37):
So, like I said, seeing peoplebeing restrained and going
against their will is not verycommon.
I mean, it does happen.
Speaker 1 (06:46):
So if you're in a situation where someone just
does not want to go to thehospital at all and you know
they need help, they might be ina situation where they may not
realize they need the help, butthey do need the help.
So what's your approach?
How do you get them to settledown, calm down and get them to
a point of where you canactually help them?
Speaker 2 (07:08):
Well, oftentimes I say that you know you're not
acting like your true self,You're not yourself these days.
Or I haven't said this often,but I have on occasion come
right out and said you're not intouch with reality, You're not
yourself, You're having a hardtime taking care of yourself,
and they've been down this roadmany times in the past.
(07:32):
The presence of police officersand security guards usually
just their presence is enoughfor them to cooperate.
Speaker 1 (07:43):
That's good.
You kind of caught me off guarda little.
I thought the presence of thepolice might be a little more
intimidating for them, so that'sreally good that it worked out.
Now, if you've seen a person acouple of times and you've gone
through all these situations,how is that handled?
Has that created a relationship, so to speak, with them, so
(08:07):
they understand you and trustyou?
Speaker 2 (08:09):
Yeah, definitely.
There are a lot of people cyclein and out of emergency
services, and so it's verycommon for me to be evaluating
someone who I have previouslyevaluated before, because the
lengths of stay on inpatientunits are usually so short and
(08:29):
there are so many prematuredischarges that patients
inevitably fall back into poorself-care and crisis mode when
they've been released fromhospitals too soon.
So we see the revolving door ofhospitalizations.
People repeatedly presentingthemselves to emergency services
(08:50):
is very common.
Speaker 1 (08:52):
So how do we fix that ?
I mean, you're in crisis modesometimes when you go out to try
and help these people.
You get them to a facility.
You see that it does help them,but then a week or two, a day
or two or whatever the timeframe may be, here they are back
in front of you again.
So what are your thoughts onhow we can mend this system so
(09:13):
you don't have to see thesepeople on a continuous basis?
Speaker 2 (09:16):
Well, there's a tool that's widely underutilized in
the United States calledassisted outpatient treatment,
and all states except forConnecticut and Massachusetts
allow this, and Washington DCallows AOT as well.
Aot is court-ordered outpatienttreatment, especially critical
(09:43):
for those with anosognosia,which means lack of awareness of
being ill.
We know that a very highpercentage of people with
schizophrenia spectrum disordershave anosognosia.
A lot of people with bipolardisorder have anosognosia as
well, and so when someone lacksinsight, of course they're not
(10:07):
going to initiate treatment orthey're not going to want to get
help, and so this anosognosiareally interferes with treatment
.
And AOT oftentimes uses theblack robe effect, which is
people they're more likely tofollow treatment plans and
(10:29):
they're more likely to followthrough with treatment when
there's a judge ordering them todo the treatment because of the
judge's power and influence,and that's called the black robe
effect.
And there have been lots ofstudies showing that AOT reduces
rates of homelessness,hospitalization and
(10:51):
incarcerations.
It also prevents violence,prevents suicides.
It's a tool that Massachusettsand Connecticut really need to
adopt if we want to see adecrease in these horrible
markers.
Speaker 1 (11:07):
Okay, you just brought up anosognosia.
Can you explain that to thelisteners so they can understand
what it is compared to otherserious mental illnesses?
Speaker 2 (11:18):
Well, psychosis involves the most anosognosia
among the serious mentalillnesses.
I can usually tell if there'slack of insight or anosognosia
involved when there's lack ofadherence to taking medications
and not attending outpatientappointments.
(11:40):
These are some red flags andsigns that there's some
anosognosia going on, and a fewstudies have shown that the rate
of anosognosia andschizophrenia spectrum disorders
can be up to even 97% for thosewho are not treated.
Speaker 1 (11:57):
So if they're being treated, then that gives them
the opportunity to lead afulfilling life and it gets rid
of all that noise that's goingon in their head.
Is that correct?
Speaker 2 (12:08):
Right, absolutely.
They'll be able to have moreorganized thought process.
Hallucinations will lessen,delusions will hopefully
dissipate.
As a result, less tragedy islikely to occur.
Speaker 1 (12:27):
So if Massachusetts was to get and pass AOT, that
would help everything thatyou're trying to do, correct?
Speaker 2 (12:36):
Definitely it would decrease the revolving door, it
would prevent tragedies fromoccurring and it would just
overall improve the functioningof those with serious mental
illness, especially those withpsychosis.
And when I say psychosis,psychosis can be medically
(13:00):
caused, but I'm just referringto psychosis in the context of
serious mental illness.
So in other words, someone withdementia or even a brain tumor
can have psychosis.
For our purposes I'm referringto just serious mental illness,
psychosis.
Speaker 1 (13:19):
Now, when you mention dementia, the first thing that
comes to mind is the elderly.
Now do you run into youngerpeople have this, or is this
mainly just for the older people?
Speaker 2 (13:30):
No, not as much.
It typically affects theelderly, so I've rarely seen
dementia affect someone who'syounger.
Speaker 1 (13:38):
So do you get calls from people that are older,
that's going through dementia?
Is that something you have todeal with as well?
Speaker 2 (13:47):
Yes, absolutely so.
As a mobile clinician, I canevaluate people in a wide
variety of settings.
Occasionally, nursing homescall us out to evaluate people.
I can evaluate people indoctor's offices, police holding
(14:07):
cells, police stations,personal homes, group homes.
One time I evaluated someone ona street sidewalk.
Another time I evaluatedsomeone in the parking lot of a
stop and shop.
Speaker 1 (14:23):
Now, when you evaluate them, you have so many
things that it can be.
I mean you've got psychosis,you've got dementia and all of
the above that you justmentioned.
You mean you've got psychosis,you've got dementia and all of
the above that you justmentioned.
You only get a limited amountof time.
You haven't seen them that much.
How do you diagnose in such ashort period of time?
I think it must be really tough.
That's my opinion.
Speaker 2 (14:45):
Well, it's tough, it's very tough work.
Even with my experience, I findthese days the work is really
tough and difficult and drainingthe diagnosis.
You know we do our best withdiagnosing but you know I'm sure
I've made mistakes.
(15:05):
The safety of patients is mostimportant in emergency work, of
patients is most important inemergency work.
So, in other words, making surethat the client is safe and
preventing danger or reducingdanger is more important than
getting the diagnosis correct inemergency services.
Speaker 1 (15:23):
Okay, you just brought up something that I
think is very important.
You just mentioned people withall the issues that they have
that you just mentioned.
So at the end of your workday,when you're trying to decompress
, you're just trying to relaxyourself.
How does this affect you?
Speaker 2 (15:42):
Well, I think, naturally there is some
desensitization which takesplace because otherwise I
wouldn't be able to function.
There has to be somecompartmentalization.
That happens and I have toremind myself that whatever
dysfunction I saw is a functionof the broken system.
(16:03):
I have to remind myself to nottake responsibility for the
negative outcomes that I see ona daily basis.
Speaker 1 (16:10):
Yeah, yeah for sure.
I mean, I know a lot of police,a lot of EMTs, a lot of people
that do everything on a dailybasis and they see these people
and there's always one or twothat just get to you.
You see them struggling, yousee them trying.
They're just having a roughtime.
So this is something you haveto deal with on a daily basis
and I just can't imagine havingto do that all the time.
So this is something you haveto deal with on a daily basis
(16:32):
and I just can't imagine havingto do that all the time.
It's tough.
Speaker 2 (16:35):
Yeah, yeah, definitely.
So it's really important totake care of myself and cope
well and process difficult caseswith supervisors and my support
system.
I'm really lucky that I havesome great colleagues, you know,
who are really supportive andknowing when I need help.
There's always an administratoron call.
(16:56):
The program I work for nevercloses, so there are social
workers like working even in themiddle of the night, helping
people in crisis, and there'salways an administrator on call
who is available to help or oncall who's available to help.
Speaker 1 (17:11):
What's one of the more things that you would
consider straightforward?
I mean, you go in there, youlook at the situation and you go
okay, this isn't gonna be toobad.
So what would you considerstraightforward for the
listeners?
I mean, I think they canvisualize the worst case
scenarios.
What's something that you lookat and you go to yourself okay,
this shouldn't be too much of achallenge?
Speaker 2 (17:30):
When someone is clearly suicidal with planned
means intent, that is a verystraightforward case.
A lot of cases involvingpsychosis can be really tricky
and involve a lot of gray areas,because there are varying
degrees of psychosis and someonecan be very psychotic with the
(17:55):
ability to take care of herselfand even have a job, clean
herself, eat, sleep, do basicfunctions.
And just because someone ispsychotic doesn't necessarily
mean that they qualify forhospitalization.
Someone can be psychotic andvery high functioning.
(18:15):
A straightforward case would beif someone tells me that he has
nothing to live for, there'snothing going on in his life
that gives him hope ormotivation to continue living,
and he has a plan to hanghimself and you know, go to Home
Depot and buy the tools for it,and he knows exactly where he's
(18:37):
going to do it, and that's acase that's like for lack of a
better word easy.
Speaker 1 (18:42):
So how do you talk him down off that cliff?
I mean, from what I understand,the ones that talking about
about it are the ones that I'mnot going to say less likely,
but sometimes will not followthrough, but the ones that don't
talk about it much, they're theones that might just go ahead
and do it because they've kindof pre-planned it.
So what do you do to help them,so that way you can talk them
(19:08):
down off that cliff?
Speaker 2 (19:10):
Well, I think praising strengths is really
important, so reminding them ofsome light, even though they're
only seeing darkness, and makingsure that the right questions
are asked.
I found that secretiveness whenit comes to suicidality is a
(19:30):
big red flag for me.
So if someone is dodging myquestions, someone is not
answering me directly when I askabout the questions pertaining
to suicide, then I get reallyconcerned.
Speaker 1 (19:44):
What happens when you have some that are thinking
about it?
They don't follow through, butyet they're thinking about it.
They go back and forth.
Is that a situation to whereyou get concerned?
Speaker 2 (19:57):
That's very common with borderline personality
disorder.
People with borderlinepersonality disorder have
oftentimes chronic dailythoughts of suicide at baseline.
Speaker 1 (20:10):
Is that something that you deal with quite often?
Speaker 2 (20:13):
A lot.
I deal with people withborderline far more often than
with autism.
Speaker 1 (20:20):
When you're dealing with someone.
That's borderline, that's notpsychotic right.
Speaker 2 (20:25):
Borderline personality disorder doesn't
involve psychosis.
It involves a lot ofsuperficial, self-injurious
behavior.
Speaker 1 (20:34):
And you deal with that situation quite a bit.
Speaker 2 (20:37):
A lot yeah, yeah.
Speaker 1 (20:40):
How do you get across to them?
I mean, they're talking aboutself-infliction, hurting
themselves.
How do you get them down offthat cliff?
Speaker 2 (20:47):
It's really tough.
It's really tough.
I evaluated a young woman withborderline at a group home who
was regularly inflictingsuperficial self-injuries her
(21:14):
even though you know she didn'twant to be hospitalized.
But they wanted me to section12 her because they were just so
burned out by her frequentself-injurious behavior and they
said that she's going to justcontinue harming herself
superficially.
And I responded with you know,unfortunately the law doesn't
allow us to hospitalize peoplebecause we predict that they're
going to superficiallyself-injure.
There's a difference betweensuperficially injuring oneself
(21:37):
and seriously injuring oneself.
So a lot of people withborderline personality disorder
are at risk for accidentallykilling themselves.
You know, lacking intent to die, killing themselves, you know,
lacking intent to die butengaging in suicidal gestures or
(21:57):
overdoses on pills and thenbecoming fatal as a result.
Speaker 1 (22:01):
Is there a certain age group?
This affects more than others.
Is it older or is it moreyounger?
Speaker 2 (22:07):
We're generally not allowed to diagnose teenagers
with borderline personalitydisorder because their
personalities have not fullydeveloped yet.
But I've evaluated teenagersthat show a lot of traits of
borderline and I've evaluatedthem thinking oh well, she's
(22:27):
definitely, they're definitelygoing to develop borderline as
an adult, because I can see thesigns early on.
It's typically it's adults whoare diagnosed with personality
disorders.
We're really not allowed todiagnose kids with personality
disorders.
Speaker 1 (22:47):
That's the first time I've heard this kind of
information, so that's kind ofimportant for people to know and
understand.
What would you like to tell ourlisteners that you think is
very important that they knowand understand about what you do
and what you're trying to do tohelp the people that need help?
Speaker 2 (23:05):
Well, my main goal is to reduce danger or prevent
danger, and to get people to asafe space.
Occasionally involvesinvoluntarily transporting them
to the hospital, and that'swhere police officers are
necessary, because I'm not ableto physically go hands on on
(23:28):
anyone who violent and or who'svery agitated, and so that's
what police are for.
So in the mental health system,the police were a necessary
evil.
Speaker 1 (23:41):
Quote-unquote yeah, they are yeah yeah, police are
there for a reason that's tohelp situations like that.
They need to step up, for sure,because you need the help and
the person there needs the help.
Situations like that.
They need to step up, for sure,because you need the help and
the person there needs the help.
Speaker 2 (23:54):
Right, right, right.
And, as I said, I have notoften seen people being
physically restrained.
I mean, of course it doeshappen, it's the nature of the
work that I do.
But the police really usephysical restraint as a last
(24:17):
resort.
They try everything else first.
Speaker 1 (24:21):
And there's so many different layers of things that
it can be, unfortunately, peoplethat don't know will clump them
all in together, and the worstis part of that situation.
So it's very important thatpeople know the differences
(24:42):
between everything so that theunderstanding is there for them
to at least have a littleempathy for them.
Speaker 2 (24:46):
Right and it's really important to understand and
tell the audience that mostpeople with mental illness are
not violent and they're morelikely to be victimized, but a
small subset of the populationwith untreated serious mental
illness, mostly involvingpsychosis, can be more violent.
Speaker 1 (25:11):
Right.
One of the things that I haveheard is the ones that are not
violent can oftentimes be thevictims, and many people think
that they are creating victimswhen they really aren't.
Speaker 2 (25:24):
Yes, yeah.
Speaker 1 (25:25):
Yeah, it's a very tough subject.
Not a lot of people want to doit because there's so much
stigma attached to it.
Then a lot of people don't wantto talk about it for that same
reason there's a lot of stigmaattached to it.
Speaker 2 (25:39):
Yes, unfortunately there is still stigma associated
with mental illness, but therereally shouldn't be, because
these are brain disorders andthe brain is part of the
physical body and it's organic.
You know, these are brain-baseddisorders that really shouldn't
be stigmatized.
Speaker 1 (25:58):
Yeah, unfortunately it's very sad.
People that think aboutpsychosis tend to go to the very
worst case scenarios.
The news media unfortunatelycarries a lot of the worst parts
of it, where people killsomebody or something bad
happens.
But, as you said, a lot ofpeople can actually thrive in
(26:19):
life.
Speaker 2 (26:19):
Yeah, absolutely, with proper treatment.
Speaker 1 (26:22):
Yeah, Well, this has been great Great conversation,
great information.
I really appreciate you takingthe time to come on.
Speaker 2 (26:29):
Oh, thank you, it was great being here.
Speaker 1 (26:32):
It's been my pleasure .
Thanks again.
Thanks for taking the time outof your busy schedule to listen
to our show today.
We hope that you enjoyed it asmuch as we enjoyed bringing it
to you.
We enjoyed it as much as weenjoyed bringing it to you.
If you know anyone that wouldlike to tell us their story,
(26:55):
send them to TonyMantorcomContact then they can give us
their information so one daythey may be a guest on our show.
One more thing we ask telleveryone everywhere about why
Not Me, the world, theconversations we're having and
(27:16):
the inspiration our guests giveto everyone everywhere that you
are not alone in this world.
Welcome to why Not Me ?
The World Podcast, hosted byTony Mantor, broadcasting from
Music City, usa, nashville,tennessee.
Join us as our guests tell ustheir stories.
Some will make you laugh, somewill make you cry.
Their stories Some will makeyou laugh, some will make you
(00:30):
cry.
Real life people who willinspire and show that you are
not alone in this world.
Hopefully, you gain moreawareness, acceptance and a
better understanding for autismAround the World.
Hi, I'm Tony Mantor.
(00:53):
Welcome to why Not Me?
The World Humanity OverHandcuffs the Silent Crisis
special event.
Joining us today is Lynn Nanos.
She is an LICSW, she has donethis for most of her life and
she is very passionate abouthelping people with serious
mental illness, especially thoseinvolving psychosis.
She brings a wealth ofexperience from her work on a
(01:17):
mobile crisis unit inMassachusetts.
She's here to share insights oncollaborating with law
enforcement, navigating complexcases and diagnosing a diverse
range of individuals in crisis.
Her expertise offers a uniqueperspective on mental health
intervention and we'reincredibly grateful for her time
(01:37):
and knowledge.
Thanks for coming on.
Speaker 2 (01:40):
I'm glad to be here.
Speaker 1 (01:42):
Yes, it's great to have you on If you could tell us
a little bit about what it isthat you do.
Speaker 2 (01:50):
So I am a mobile psychiatric emergency social
worker in Massachusetts.
I am in 15th year of full-timework and previously I worked for
another emergency servicesagency for two years.
(02:11):
So all in all, that's manyyears of doing mobile crisis
work, in which I assess peoplewho are in crisis and determine
whether they need to behospitalized, and if they don't
need to be hospitalized, I canrefer them to outpatient
treatment programs or give themself-help material.
(02:35):
I'm an LICSW which is LicensedIndependent Clinical Social
Worker, and that gives me theability to authorize involuntary
transfers to the hospital forpeople who are unsafe.
Speaker 1 (02:52):
Do you work with the police alongside them or, lots
of times, do you work withoutthem?
Speaker 2 (02:58):
Some cases involve referrals from police officers
and other cases don't involvethe police, so it really varies.
Speaker 1 (03:06):
So, when you are involved with the police, what's
the criteria for you to workwith them so you can get
everything you need undercontrol and create a better
situation for everyone involved?
Speaker 2 (03:18):
Well, I do a psychiatric evaluation with the
police and I try to divert themaway from the criminal justice
system, from being arrested.
I can authorize involuntaryholds, which in Massachusetts is
called a Section 12.
And if the person in crisis isout of control and uncooperative
(03:45):
and not willing to go to thehospital, the police can help to
, along with me, persuade theperson to agree to
hospitalization.
They use restraint as a lastresort and I typically don't see
people being restrained becausewe can usually persuade them to
agree to the hospitalization,but occasionally they have to be
(04:09):
forcibly restrained.
Speaker 1 (04:11):
So if it does get out of control, where they have to
be restrained and they needmedication, is that done there
or at a different time?
Speaker 2 (04:19):
I don't have anything to do with medication.
Have anything to do withmedication.
The medication occurs at thehospital setting like after
they're transported to thehospital.
Speaker 1 (04:35):
Okay, that makes sense.
So what led you to get intothis business?
It's not your everyday nine tofive job that people think of,
so what drew you to doing thisprofession?
Speaker 2 (04:41):
Well, I've always been most invigorated by helping
the sickest of the sick, thepeople who are least functional.
I really enjoy helping people.
I always found it really, youknow, tragically ironic that the
people who are most sick seemto be the least helped by the
(05:03):
government.
They seem to be the mostunderserved, and this motivates
me to want to help them, and soI've always felt most
comfortable dealing with peoplewho are very sick, with
psychosis usually.
Speaker 1 (05:17):
I think that's great.
So what's your first approach?
When you first come onto thescene?
How do you handle this with theperson that you're going to be
looking at and ultimately tryingto help out?
So what's the first thing thatyou do?
Speaker 2 (05:31):
Well, I begin with telling them that I want to get
to know them a little bit, askthem a few questions to try to
figure out how to best help themout.
And I ask some backgroundquestions.
And then, of course, there arethe safety questions which are
critical.
There are questions involvinghistory of past suicide attempts
(05:53):
, history of hallucinations,whether the person is suicidal
or having any thoughts ofwanting to harm others.
Right now I use my instinct andmy gut a lot, because I've been
doing this work for many years.
I can tell if someone needs tobe hospitalized, usually pretty
(06:16):
quickly.
Sometimes it takes longer thanother times, but I think my
instinct has been well-developedat this point so that I can
determine pretty quickly ifsomeone needs to be
involuntarily transferred to thehospital or voluntarily
hospitalized.
They usually go voluntarily.
(06:37):
So, like I said, seeing peoplebeing restrained and going
against their will is not verycommon.
I mean, it does happen.
Speaker 1 (06:46):
So if you're in a situation where someone just
does not want to go to thehospital at all and you know
they need help, they might be ina situation where they may not
realize they need the help, butthey do need the help.
So what's your approach?
How do you get them to settledown, calm down and get them to
a point of where you canactually help them?
Speaker 2 (07:08):
Well, oftentimes I say that you know you're not
acting like your true self,You're not yourself these days.
Or I haven't said this often,but I have on occasion come
right out and said you're not intouch with reality, You're not
yourself, You're having a hardtime taking care of yourself,
and they've been down this roadmany times in the past.
(07:32):
The presence of police officersand security guards usually
just their presence is enoughfor them to cooperate.
Speaker 1 (07:43):
That's good.
You kind of caught me off guarda little.
I thought the presence of thepolice might be a little more
intimidating for them, so that'sreally good that it worked out.
Now, if you've seen a person acouple of times and you've gone
through all these situations,how is that handled?
Has that created a relationship, so to speak, with them, so
(08:07):
they understand you and trustyou?
Speaker 2 (08:09):
Yeah, definitely.
There are a lot of people cyclein and out of emergency
services, and so it's verycommon for me to be evaluating
someone who I have previouslyevaluated before, because the
lengths of stay on inpatientunits are usually so short and
(08:29):
there are so many prematuredischarges that patients
inevitably fall back into poorself-care and crisis mode when
they've been released fromhospitals too soon.
So we see the revolving door ofhospitalizations.
People repeatedly presentingthemselves to emergency services
(08:50):
is very common.
Speaker 1 (08:52):
So how do we fix that ?
I mean, you're in crisis modesometimes when you go out to try
and help these people.
You get them to a facility.
You see that it does help them,but then a week or two, a day
or two or whatever the timeframe may be, here they are back
in front of you again.
So what are your thoughts onhow we can mend this system so
(09:13):
you don't have to see thesepeople on a continuous basis?
Speaker 2 (09:16):
Well, there's a tool that's widely underutilized in
the United States calledassisted outpatient treatment,
and all states except forConnecticut and Massachusetts
allow this, and Washington DCallows AOT as well.
Aot is court-ordered outpatienttreatment, especially critical
(09:43):
for those with anosognosia,which means lack of awareness of
being ill.
We know that a very highpercentage of people with
schizophrenia spectrum disordershave anosognosia.
A lot of people with bipolardisorder have anosognosia as
well, and so when someone lacksinsight, of course they're not
(10:07):
going to initiate treatment orthey're not going to want to get
help, and so this anosognosiareally interferes with treatment
.
And AOT oftentimes uses theblack robe effect, which is
people they're more likely tofollow treatment plans and
(10:29):
they're more likely to followthrough with treatment when
there's a judge ordering them todo the treatment because of the
judge's power and influence,and that's called the black robe
effect.
And there have been lots ofstudies showing that AOT reduces
rates of homelessness,hospitalization and
(10:51):
incarcerations.
It also prevents violence,prevents suicides.
It's a tool that Massachusettsand Connecticut really need to
adopt if we want to see adecrease in these horrible
markers.
Speaker 1 (11:07):
Okay, you just brought up anosognosia.
Can you explain that to thelisteners so they can understand
what it is compared to otherserious mental illnesses?
Speaker 2 (11:18):
Well, psychosis involves the most anosognosia
among the serious mentalillnesses.
I can usually tell if there'slack of insight or anosognosia
involved when there's lack ofadherence to taking medications
and not attending outpatientappointments.
(11:40):
These are some red flags andsigns that there's some
anosognosia going on, and a fewstudies have shown that the rate
of anosognosia andschizophrenia spectrum disorders
can be up to even 97% for thosewho are not treated.
Speaker 1 (11:57):
So if they're being treated, then that gives them
the opportunity to lead afulfilling life and it gets rid
of all that noise that's goingon in their head.
Is that correct?
Speaker 2 (12:08):
Right, absolutely.
They'll be able to have moreorganized thought process.
Hallucinations will lessen,delusions will hopefully
dissipate.
As a result, less tragedy islikely to occur.
Speaker 1 (12:27):
So if Massachusetts was to get and pass AOT, that
would help everything thatyou're trying to do, correct?
Speaker 2 (12:36):
Definitely it would decrease the revolving door, it
would prevent tragedies fromoccurring and it would just
overall improve the functioningof those with serious mental
illness, especially those withpsychosis.
And when I say psychosis,psychosis can be medically
(13:00):
caused, but I'm just referringto psychosis in the context of
serious mental illness.
So in other words, someone withdementia or even a brain tumor
can have psychosis.
For our purposes I'm referringto just serious mental illness,
psychosis.
Speaker 1 (13:19):
Now, when you mention dementia, the first thing that
comes to mind is the elderly.
Now do you run into youngerpeople have this, or is this
mainly just for the older people?
Speaker 2 (13:30):
No, not as much.
It typically affects theelderly, so I've rarely seen
dementia affect someone who'syounger.
Speaker 1 (13:38):
So do you get calls from people that are older,
that's going through dementia?
Is that something you have todeal with as well?
Speaker 2 (13:47):
Yes, absolutely so.
As a mobile clinician, I canevaluate people in a wide
variety of settings.
Occasionally, nursing homescall us out to evaluate people.
I can evaluate people indoctor's offices, police holding
(14:07):
cells, police stations,personal homes, group homes.
One time I evaluated someone ona street sidewalk.
Another time I evaluatedsomeone in the parking lot of a
stop and shop.
Speaker 1 (14:23):
Now, when you evaluate them, you have so many
things that it can be.
I mean you've got psychosis,you've got dementia and all of
the above that you justmentioned.
You mean you've got psychosis,you've got dementia and all of
the above that you justmentioned.
You only get a limited amountof time.
You haven't seen them that much.
How do you diagnose in such ashort period of time?
I think it must be really tough.
That's my opinion.
Speaker 2 (14:45):
Well, it's tough, it's very tough work.
Even with my experience, I findthese days the work is really
tough and difficult and drainingthe diagnosis.
You know we do our best withdiagnosing but you know I'm sure
I've made mistakes.
(15:05):
The safety of patients is mostimportant in emergency work, of
patients is most important inemergency work.
So, in other words, making surethat the client is safe and
preventing danger or reducingdanger is more important than
getting the diagnosis correct inemergency services.
Speaker 1 (15:23):
Okay, you just brought up something that I
think is very important.
You just mentioned people withall the issues that they have
that you just mentioned.
So at the end of your workday,when you're trying to decompress
, you're just trying to relaxyourself.
How does this affect you?
Speaker 2 (15:42):
Well, I think, naturally there is some
desensitization which takesplace because otherwise I
wouldn't be able to function.
There has to be somecompartmentalization.
That happens and I have toremind myself that whatever
dysfunction I saw is a functionof the broken system.
(16:03):
I have to remind myself to nottake responsibility for the
negative outcomes that I see ona daily basis.
Speaker 1 (16:10):
Yeah, yeah for sure.
I mean, I know a lot of police,a lot of EMTs, a lot of people
that do everything on a dailybasis and they see these people
and there's always one or twothat just get to you.
You see them struggling, yousee them trying.
They're just having a roughtime.
So this is something you haveto deal with on a daily basis
and I just can't imagine havingto do that all the time.
So this is something you haveto deal with on a daily basis
(16:32):
and I just can't imagine havingto do that all the time.
It's tough.
Speaker 2 (16:35):
Yeah, yeah, definitely.
So it's really important totake care of myself and cope
well and process difficult caseswith supervisors and my support
system.
I'm really lucky that I havesome great colleagues, you know,
who are really supportive andknowing when I need help.
There's always an administratoron call.
(16:56):
The program I work for nevercloses, so there are social
workers like working even in themiddle of the night, helping
people in crisis, and there'salways an administrator on call
who is available to help or oncall who's available to help.
Speaker 1 (17:11):
What's one of the more things that you would
consider straightforward?
I mean, you go in there, youlook at the situation and you go
okay, this isn't gonna be toobad.
So what would you considerstraightforward for the
listeners?
I mean, I think they canvisualize the worst case
scenarios.
What's something that you lookat and you go to yourself okay,
this shouldn't be too much of achallenge?
Speaker 2 (17:30):
When someone is clearly suicidal with planned
means intent, that is a verystraightforward case.
A lot of cases involvingpsychosis can be really tricky
and involve a lot of gray areas,because there are varying
degrees of psychosis and someonecan be very psychotic with the
(17:55):
ability to take care of herselfand even have a job, clean
herself, eat, sleep, do basicfunctions.
And just because someone ispsychotic doesn't necessarily
mean that they qualify forhospitalization.
Someone can be psychotic andvery high functioning.
(18:15):
A straightforward case would beif someone tells me that he has
nothing to live for, there'snothing going on in his life
that gives him hope ormotivation to continue living,
and he has a plan to hanghimself and you know, go to Home
Depot and buy the tools for it,and he knows exactly where he's
(18:37):
going to do it, and that's acase that's like for lack of a
better word easy.
Speaker 1 (18:42):
So how do you talk him down off that cliff?
I mean, from what I understand,the ones that talking about
about it are the ones that I'mnot going to say less likely,
but sometimes will not followthrough, but the ones that don't
talk about it much, they're theones that might just go ahead
and do it because they've kindof pre-planned it.
So what do you do to help them,so that way you can talk them
(19:08):
down off that cliff?
Speaker 2 (19:10):
Well, I think praising strengths is really
important, so reminding them ofsome light, even though they're
only seeing darkness, and makingsure that the right questions
are asked.
I found that secretiveness whenit comes to suicidality is a
(19:30):
big red flag for me.
So if someone is dodging myquestions, someone is not
answering me directly when I askabout the questions pertaining
to suicide, then I get reallyconcerned.
Speaker 1 (19:44):
What happens when you have some that are thinking
about it?
They don't follow through, butyet they're thinking about it.
They go back and forth.
Is that a situation to whereyou get concerned?
Speaker 2 (19:57):
That's very common with borderline personality
disorder.
People with borderlinepersonality disorder have
oftentimes chronic dailythoughts of suicide at baseline.
Speaker 1 (20:10):
Is that something that you deal with quite often?
Speaker 2 (20:13):
A lot.
I deal with people withborderline far more often than
with autism.
Speaker 1 (20:20):
When you're dealing with someone.
That's borderline, that's notpsychotic right.
Speaker 2 (20:25):
Borderline personality disorder doesn't
involve psychosis.
It involves a lot ofsuperficial, self-injurious
behavior.
Speaker 1 (20:34):
And you deal with that situation quite a bit.
Speaker 2 (20:37):
A lot yeah, yeah.
Speaker 1 (20:40):
How do you get across to them?
I mean, they're talking aboutself-infliction, hurting
themselves.
How do you get them down offthat cliff?
Speaker 2 (20:47):
It's really tough.
It's really tough.
I evaluated a young woman withborderline at a group home who
was regularly inflictingsuperficial self-injuries her
(21:14):
even though you know she didn'twant to be hospitalized.
But they wanted me to section12 her because they were just so
burned out by her frequentself-injurious behavior and they
said that she's going to justcontinue harming herself
superficially.
And I responded with you know,unfortunately the law doesn't
allow us to hospitalize peoplebecause we predict that they're
going to superficiallyself-injure.
There's a difference betweensuperficially injuring oneself
(21:37):
and seriously injuring oneself.
So a lot of people withborderline personality disorder
are at risk for accidentallykilling themselves.
You know, lacking intent to die, killing themselves, you know,
lacking intent to die butengaging in suicidal gestures or
(21:57):
overdoses on pills and thenbecoming fatal as a result.
Speaker 1 (22:01):
Is there a certain age group?
This affects more than others.
Is it older or is it moreyounger?
Speaker 2 (22:07):
We're generally not allowed to diagnose teenagers
with borderline personalitydisorder because their
personalities have not fullydeveloped yet.
But I've evaluated teenagersthat show a lot of traits of
borderline and I've evaluatedthem thinking oh well, she's
(22:27):
definitely, they're definitelygoing to develop borderline as
an adult, because I can see thesigns early on.
It's typically it's adults whoare diagnosed with personality
disorders.
We're really not allowed todiagnose kids with personality
disorders.
Speaker 1 (22:47):
That's the first time I've heard this kind of
information, so that's kind ofimportant for people to know and
understand.
What would you like to tell ourlisteners that you think is
very important that they knowand understand about what you do
and what you're trying to do tohelp the people that need help?
Speaker 2 (23:05):
Well, my main goal is to reduce danger or prevent
danger, and to get people to asafe space.
Occasionally involvesinvoluntarily transporting them
to the hospital, and that'swhere police officers are
necessary, because I'm not ableto physically go hands on on
(23:28):
anyone who violent and or who'svery agitated, and so that's
what police are for.
So in the mental health system,the police were a necessary
evil.
Speaker 1 (23:41):
Quote-unquote yeah, they are yeah yeah, police are
there for a reason that's tohelp situations like that.
They need to step up, for sure,because you need the help and
the person there needs the help.
Situations like that.
They need to step up, for sure,because you need the help and
the person there needs the help.
Speaker 2 (23:54):
Right, right, right.
And, as I said, I have notoften seen people being
physically restrained.
I mean, of course it doeshappen, it's the nature of the
work that I do.
But the police really usephysical restraint as a last
(24:17):
resort.
They try everything else first.
Speaker 1 (24:21):
And there's so many different layers of things that
it can be, unfortunately, peoplethat don't know will clump them
all in together, and the worstis part of that situation.
So it's very important thatpeople know the differences
(24:42):
between everything so that theunderstanding is there for them
to at least have a littleempathy for them.
Speaker 2 (24:46):
Right and it's really important to understand and
tell the audience that mostpeople with mental illness are
not violent and they're morelikely to be victimized, but a
small subset of the populationwith untreated serious mental
illness, mostly involvingpsychosis, can be more violent.
Speaker 1 (25:11):
Right.
One of the things that I haveheard is the ones that are not
violent can oftentimes be thevictims, and many people think
that they are creating victimswhen they really aren't.
Speaker 2 (25:24):
Yes, yeah.
Speaker 1 (25:25):
Yeah, it's a very tough subject.
Not a lot of people want to doit because there's so much
stigma attached to it.
Then a lot of people don't wantto talk about it for that same
reason there's a lot of stigmaattached to it.
Speaker 2 (25:39):
Yes, unfortunately there is still stigma associated
with mental illness, but therereally shouldn't be, because
these are brain disorders andthe brain is part of the
physical body and it's organic.
You know, these are brain-baseddisorders that really shouldn't
be stigmatized.
Speaker 1 (25:58):
Yeah, unfortunately it's very sad.
People that think aboutpsychosis tend to go to the very
worst case scenarios.
The news media unfortunatelycarries a lot of the worst parts
of it, where people killsomebody or something bad
happens.
But, as you said, a lot ofpeople can actually thrive in
(26:19):
life.
Speaker 2 (26:19):
Yeah, absolutely, with proper treatment.
Speaker 1 (26:22):
Yeah, Well, this has been great Great conversation,
great information.
I really appreciate you takingthe time to come on.
Speaker 2 (26:29):
Oh, thank you, it was great being here.
Speaker 1 (26:32):
It's been my pleasure .
Thanks again.
Thanks for taking the time outof your busy schedule to listen
to our show today.
We hope that you enjoyed it asmuch as we enjoyed bringing it
to you.
We enjoyed it as much as weenjoyed bringing it to you.
If you know anyone that wouldlike to tell us their story,
(26:55):
send them to TonyMantorcomContact then they can give us
their information so one daythey may be a guest on our show.
One more thing we ask telleveryone everywhere about why
Not Me, the world, theconversations we're having and
(27:16):
the inspiration our guests giveto everyone everywhere that you
are not alone in this world.
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