Lynn Nanos
Appearances
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So there are social workers like working even in the middle of the night, helping people in crisis. And there's always an administrator on call who's available to help.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
When someone is clearly suicidal with planned means intent, that is a very straightforward case. A lot of cases involving psychosis can be really tricky and involve a lot of gray areas because there are varying degrees of psychosis. And someone can be very psychotic with the ability to take care of herself and even have a job. clean herself, eat, sleep, do basic functions.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And just because someone is psychotic doesn't necessarily mean that they qualify for hospitalization. Someone can be psychotic and very high functioning. A straightforward case would be if someone tells me that he has nothing to live for. There's nothing going on in his life that gives him hope or motivation to continue living.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So I am a mobile psychiatric emergency social worker in Massachusetts. I am in my 15th year of full-time work, and previously I worked as for another emergency services agency for two years. So all in all, that's many years of doing mobile crisis work in which I assess people who are in crisis and determine whether they need to be hospitalized.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And he has a plan to hang himself and, you know, go to Home Depot and buy the tools for it. And he knows exactly where he's going to do it. And that's a case that's like, for lack of a better word, easy.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, I think praising strengths is really important. So reminding them of some light, even though they're only seeing darkness, and making sure that the right questions are asked. I found that... Secretiveness when it comes to suicidality is a big red flag for me.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So if someone is dodging my questions, someone is not answering me directly when I ask about the questions pertaining to suicide, then I get really concerned.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
That's very common with borderline personality disorder. People with borderline personality disorder have oftentimes chronic daily thoughts of suicide at baseline.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
A lot. I deal with people with borderline far more often than with autism.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Borderline personality disorder doesn't involve psychosis. It involves a lot of superficial self-injurious behavior.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
A lot, yeah, yeah.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
It's really tough. It's really tough. I evaluated a young woman with borderline at a group home who was regularly inflicting superficial self-injuries. And the group home staff said, you know, wanted me to hospitalize her even though, you know, she didn't want to be hospitalized, but they wanted me to section 12 her because they were just so burned out by her frequent self-injurious behavior.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And they said that she's going to just continue harming herself superficially. And I responded with, you know, unfortunately, the law doesn't allow us to hospitalize people because we predict that they're going to superficially self-injure. There's a difference between superficially injuring oneself and seriously injuring oneself.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So a lot of people with borderline personality disorder are at risk for accidentally killing themselves, you know, lacking intent to die, but engaging in suicidal gestures or overdoses on pills and then becoming fatal as a result.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
We're generally not allowed to diagnose teenagers with borderline personality disorder because their personalities have not fully developed yet. But I've evaluated teenagers that show a lot of traits differently.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
borderline and I've evaluated them thinking oh well she's definitely they're definitely going to develop borderline as an adult because I can see the signs early on it's typically it's adults who are diagnosed with personality disorders we're really not allowed to diagnose kids with personality disorders
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, my main goal is to reduce danger or prevent danger and to get people to a safe space. Occasionally involves involuntarily transporting them to the hospital. And that's where police officers are necessary because I'm not able to physically go hands on. on anyone who's violent or who's very agitated. And so that's what police are for.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So in the mental health system, the police are a necessary evil, quote-unquote.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yeah.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Right, right, right. And as I said, I have not often seen people being physically restrained. I mean, of course it does happen. It's the nature of the work that I do. But the police really use physical restraint as a last resort. They try everything else first.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And if they don't need to be hospitalized, I can refer them to outpatient treatment programs or give them self-help material. I'm an LICSW, which is Licensed Independent Clinical Social Worker, and that gives me the ability to authorize involuntary transfers to the hospital for people who are unsafe.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Right. And it's really important to understand and tell the audience that most people with mental illness are not violent and they're more likely to be victimized. But a small subset of the population with untreated, serious mental illness, mostly involving psychosis, can be more violent.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yes. Yeah.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yes, unfortunately, there is still stigma associated with mental illness, but there really shouldn't be because these are brain disorders and the brain is part of the physical body and it's organic. You know, these are brain-based disorders that really shouldn't be stigmatized.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yeah, absolutely, with proper treatment. Yeah.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Oh, thank you. It was great being here.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Some cases involve referrals from police officers, and other cases don't involve the police. So it really varies.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, I do a psychiatric evaluation with the police and I try to divert them away from the criminal justice system from being arrested. I can authorize involuntary holds. which in Massachusetts is called a Section 12. And if the person in crisis is out of control and uncooperative and not willing to go to the hospital, the police can help to, along with me, persuade them
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
the person to agree to hospitalization. They use restraint as a last resort, and I typically don't see people being restrained because we can usually persuade them to agree to the hospitalization, but occasionally they have to be forcibly restrained.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
I don't have anything to do with medication. The medication occurs at the hospital setting, like after they're transported to the hospital.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, I've always been most invigorated by helping the sickest of the sick, the people who are least functional. I really enjoy helping people. I always found it really, you know, tragically ironic that the people who are most sick seem to be the least helped by the government. They seem to be the most underserved people. And this motivates me to want to help them.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And so I've always felt most comfortable dealing with people who are very sick with psychosis usually.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, I begin with telling them that I want to get to know them a little bit, ask them a few questions to try to figure out how to best help them out. And I ask some background questions. And then, of course, there are the safety questions, which are critical. There are questions involving history of past suicide attempts.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
history of hallucinations, whether the person is suicidal or having any thoughts of wanting to harm others right now. I use my instinct and my gut a lot because I've been doing this work for many years. I can tell if someone needs to be hospitalized usually pretty quickly.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Sometimes it takes longer than other times, but I think my instinct has been well-developed at this point so that I can determine pretty quickly if someone needs to be involuntarily transferred to the hospital or voluntarily hospitalized. They usually go voluntarily. So like I said, seeing people being restrained and going against their will is not very common. I mean, it does happen.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
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 in touch with reality. You're not yourself. You're having a hard time taking care of yourself. And they've been down this road many times in the past.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
The presence of police officers and security guards, usually just their presence is enough for them to cooperate.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yeah, definitely. There are a lot of people cycle in and out of emergency services. And so it's very common for me to be evaluating someone who I have previously evaluated before because the lengths of stay on inpatient units are usually so short and there are so many premature discharges that patients...
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
inevitably fall back into poor self-care and crisis mode when they've been released from hospitals too soon. So we see the revolving door of hospitalizations, people repeatedly presenting themselves to emergency services is very common.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, there's a tool that's widely underutilized in the United States called Assisted Outpatient Treatment. And all states except for Connecticut and Massachusetts allow this. And Washington, D.C. allows AOT as well. AOT is Court Ordered Outpatient Treatment. especially critical for those with anosognosia, which means lack of awareness of being ill.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
We know that a very high percentage of people with schizophrenia spectrum disorders have anosognosia. A lot of people with bipolar disorder have anosognosia as well. And so when someone lacks insight, of course, they're not going to initiate treatment or they're not going to want to get help. And so this anosognosia really interferes with treatment.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And AOT oftentimes uses the black robe effect, which is People, they're more likely to follow treatment plans and they're more likely to follow through with treatment when there's a judge ordering them to do the treatment because of the judge's power and influence. And that's called the black robe effect.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And there have been lots of studies showing that AOT reduces rates of homelessness, hospitalization and incarcerations. It also prevents violence, prevents suicides. It's a tool that Massachusetts and Connecticut really need to adopt if we want to see a decrease in these horrible markers.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, psychosis involves the most anosognosia among the serious mental illnesses. I can usually tell if there's lack of insight or anosognosia involved when there's lack of adherence to taking medications. and not attending outpatient appointments. These are some red flags and signs that there's some anosognosia going on.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
And a few studies have shown that the rate of anosognosia in schizophrenia spectrum disorders can be up to even 97% for those who are not treated.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Right, absolutely. They'll be able to have more organized thought process. Hallucinations will lessen. Delusions will hopefully dissipate. As a result, less tragedy is likely to occur.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Definitely. It would decrease the revolving door. It would prevent tragedies from occurring. And it would just overall improve the functioning of those with serious mental illness, especially those with psychosis. And when I say psychosis, psychosis can be medically caused, but I'm just referring to psychosis in the context of serious mental illness.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
So in other words, someone with dementia or even a brain tumor can have psychosis. For our purposes, I'm referring to just serious mental illness, psychosis.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
No, not as much. It typically affects the elderly. So I've rarely seen dementia affect someone who's younger.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yes, absolutely. So as a mobile clinician, I can evaluate people in a wide variety of settings. Occasionally, nursing homes call us out to evaluate people. I can evaluate people in doctor's offices, police holding cells, police stations, personal homes, group homes. One time I evaluated someone on a street sidewalk. Another time I evaluated someone in the parking lot of a stop and shop.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, it's tough. It's very tough work. Even with my experience, I find these days the work is really tough and difficult and draining. The diagnosis, we do our best with diagnosing, but I'm sure I've made mistakes. The safety of patients is most important in emergency work. So in other words, making sure that the client is safe
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
and preventing danger or reducing danger is more important than getting the diagnosis correct in emergency services.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Well, I think naturally there is some desensitization which takes place because otherwise I wouldn't be able to function. There has to be some compartmentalization that happens. And I have to remind myself that whatever dysfunction I saw is a function of the broken system. I have to remind myself to not take responsibility for the negative outcomes that I see on a daily basis.
Tony Mantor: Why Not Me the World
Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective
Yeah, yeah, definitely. So it's really important to take care of myself and cope well and process difficult cases with supervisors and my support system. I'm really lucky that I have some great colleagues, you know, who are really supportive and knowing when I need help. There's always an administrator on call. The program I work for never closes.