Lynn Nanos: Navigating Psychosis: A Mobile Crisis Worker's Perspective

Welcome to Why Not Me the World? Podcast hosted by
Tony Mantor, broadcasting from Music City, USA, Nashville, Tennessee. Join
us as our guests tell us their stories. Some will
make you laugh, some will make you cry. Real life
people who will inspire and show that you are not
alone in this world. Hopefully you gain more awareness, acceptance,
and a better understanding for autism around the world. Hi,
Tony Mantor, Welcome to Why Not Me the World? Humanity
over Handcuffs the Silent Crisis special event. Joining us day
is Lynn Nanos. She is an licsw She has done
this for most of her life, and she is very
passionate about helping people with serious mental illness, especially those
involving psychosis. She brings the wealth of experience from her
work on a mobile crisis unit in Massachusetts. She's here
to share insights on collaborating with law enforcement, navigating complex cases,
and diagnosing a diverse range of individuals in crisis. Her
expertise offers a unique perspective on mental health intervention and
we're incredibly grateful for her time and knowledge. Thanks for
coming on.
I'm glad to be here.
Yes, it's great to have you on if you could
tell us a little bit about what it is that
you do. So.
I am a mobile psychiatric emergency social worker in Massachusetts.
I am in my fifteenth year of full time work,
and previously I worked 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,
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.
Do you work with a police alongside them or lots
of times do you work without them.
Some cases involved refer roles from police officers and other cases.
Don't involve the police, so it really varies.
So when you are involved with the police, what's the
criteria for you to work with them so you can
get everything you need under control and create a better
situation for everyone involved.
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 colds, which
in Massachusetts is called a Section twelve, And if the
person and crisis is out of control and uncooperative and
not willing to go to the hospital, the police can
help to along with me persuade the person to agree
to hospitalization. They use restraint as a last resort. 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.
So if it does get out of control where they
have to be restrained and they need medication, is that
done there or at a different time.
I don't have anything to do with medication.
The medication occurs at the hospital setting, like after they're
transported to the hospital.
Okay, that makes sense. So what led you to get
into this business. It's not your everyday nine to five
job that people think of. So what drew you to
doing this profession?
Well, I've always been most invigorated by helping the sickest
of the sec 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 ho was sick
seem to be the least helped by the government. They
seem to be the most underserved, and this motivates me
to want to help them. And so I've always felt
most comfortable dealing with people who are very sick with psychosis.
Usually I think that's great. So what's your first approach
when you first come onto the scene. How do you
handle this with the person that you're going to be
looking at and ultimately trying to help out. So what's
the first thing that you do? 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, history
of hallucinations, whether the person is suicide 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. 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.
So if you're in a situation where someone just does
not want to go to the hospital at all, and
you know they need help, they might be in a
situation where they may not realize they need the help,
but they do need the help. So what's your coach,
How do you get them to settle down, calm down,
and get them to a point of where you can
actually help them.
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.
The presence of police officers and security guards, usually just
their presence is enough for them to cooperate.
That's good. You kind of caught me off guard a little.
I thought the presence of the police might be a
little more intimidating for them. So that's really good that
it worked out. Now, if you've seen a person a
couple 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 they understand you and trust you?
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 inevitably fall back into poor self care and crisis.
Mode when they've been released.
From hospitals too sound, so we see the revolving door
of hospitalizations. People repeatedly presenting themselves to emergency services is
very common.
So how do we fix that? I mean, you're in
crisis mode sometimes 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 on how we can mend
this system so you don't have to see these people
on a continuous basis.
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 DC allows AOT
as well. AOT is court ordered outpatient treatment, especially critical
for those with a sygnosia, which means lack of awareness
of being ill. We know that a very high percentage
of people with schizophrenia spectrum disorders have on a signosia.
A lot of people with bipolar disorder have on a
sygnosia 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 on a signosa really interferes with treatment.
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.
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.
Okay, you just brought up antisygnosia. Can you explain that
to the listeners so they can understand what it is
compared to other serious mental illnesses.
Well, psychosis involves the most anasgnosia among the serious mental illnesses.
I can usually tell if there's lack of insight or
anasignosia 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 antasignosia going on. And a
few studies have shown that the rate of nasignosia and
schizophrenia spectrum disorders can be up to even ninety seven
percent for those who are not treated.
So if they're being treated, then that gives them the
opportunity to lead a fulfilling life and it gets rid
of all that noise that is going on in the head.
Is that correct?
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.
So if Massachusetts was to get and pass AOT, that
would help everything that you're trying to do.
Correct 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, psychosis.
Can be medically clause, but I'm just referring.
To psychosis in the context of serious mental illness. 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.
Now, when you mentioned dementia, the first thing that comes
to mind is the elderly. Now do you run into
younger people have this or is this mainly just for
the older people?
No, not as much.
It typically affects the elderly, so I've rarely seen dementia
affect someone who's younger.
So do you get calls from people that are older
that's going through dementia. Is that something you have to
deal with as well?
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 doctors' 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.
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 just mentioned.
You only get a limited amount of time. You haven't
seen them that much. How do you diagnose in such
a short period of time. I think it must be
really tough, that's my opinion.
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. You know,
we do our best with diagnosing, but you know, 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, and preventing danger or reducing
danger is more important than getting the.
Diagnosis correct in emergency services.
Okay, you just brought up something that I think is
very important. You just mentioned people with all the issues
that they have that you just mentioned. So at the
end of your work day, when you're trying to decompress,
you're just trying to relax yourself, How does this affect you?
Well, I think naturally there's 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.
Yeah, yeah, for sure. I mean I know a lot
of police, a lot of amts, a lot of people
that do everything on a daily basis, and they see
these people and there's always one or two that just
get to you. You see them struggling, you see him trying,
They're just having a rough time. So this is something
you have to deal with on a daily basis. And
I just can't imagine having to do that all the
time is tough.
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 close it, 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.
What's one of the more things that you would consider straightforward?
I mean, you go in there, you look at the situation,
and you go, Okay, this isn't going to be too bad.
So what would you consider straightforward for the listeners? I mean,
I think they can visualize the worst case scenarios. What's
something that you look at and you go to yourself, Okay,
this shouldn't be too much of a challenge.
When someone is clearly suicidal with plan 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 yourself and even have a job, clean herself, eat, sleep,
do basic functions. 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, and he has a
plan to hang himself, and you go to a 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.
So how do you talk him down off that cliffs?
I mean, from what I understand, the ones that talking
about it are the ones that I'm not going to
say less likely but sometimes will not follow through. But
the ones that don't talk about it much, they're the
ones that might just go ahead and do it because
they've kind of pre planned it. So what do you
do to help them so that way you can talk
them down off that cliff?
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. So if someone is dodging
my questions, someone is not answering me directly what I
ask about the questions pertaining to suicide, then I get
really concerned.
What happens when you have some that are thinking about it?
They don't follow through but yet to thinking about it.
They go back and forth. Is that a situation to
where you get concerned?
That's very common with border line personality disorder? People with
borderline personality disorder have oftentimes chronic daily thoughts of suicide
at baseline.
Is that something that you deal with quite often a lot.
I deal with people people with borderline far more often
than with autism.
When you're dealing with someone that borderline that's not psychotic, right.
Borderline personality disorder doesn't involve psychosis. It involves a lot
of superficial self injurious.
Behavior, and you deal with that situation quite a bit
a lot.
Yeah.
Yeah, How do you get across to them. I mean,
they're talking about self infliction, hurting themselves. How do you
get them down off that cliffs?
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, you know, wanted me to hospitalize her,
even though you know, she didn't want to be hospitalized,
but they wanted me to to Section twelve because they
were just so burned out by her frequent self injurist behavior.
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. 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.
Is there a certain age group this affects more than others.
Is it older or is it more younger.
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 of 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.
That's the first time I've heard this kind of information,
So that's kind of important for people to know and understand.
What would you like to tell our listeners that you
think is very important that they know and understand about
what you do and what you're trying to do to
help the people that need help.
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. So in the
mental health system, the police are a necessary evil quote.
Unquote, yeah they are. Yeah, yeah, police are there for
a reason. That's to help situations like that. They need
to step up for sure, because you need the help
and the person there needs the help, 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 restrained as a last resort. They try everything
else first.
Yeah, that's good. I mean, when you get into the
mental illness part of it, there's psychosis and there's so
many different layers of things that it can be. Unfortunately,
people that don't know will clump them all in together,
and the worst is part of that situation. So it's
very important that people know the differences between everything so
that the understandings there form to at least have a
little empathy for them, 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. That's what a small
subset of the population with untreated serious mental illness mostly
involving psychosis can be more violent, right.
One of the things that I have heard is the
ones that are not violent can oftentimes be the victims,
and many people think that they are creating victims when
they really aren't.
Yes.
Yeah, Yeah, it's a very tough subject. Not a lot
of people want to do it because there's so much
stigma attached to it. Then a lot of people don't
want to talk about it for that same reason. There's
a lot of stigma attached to it.
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. Yeah.
Unfortunately, it's very sad. People that think about psychosis tend
to go to the very worst case scenarios. The news
media unfortunately carries a lot of the worst parts of it,
where people kill somebody or something bad happens. But as
you said, a lot of people can actually thrive in life.
Yeah, absolutely with proper treatment.
Yeah.
Well, this has been great, great conversation, great information. I
really appreciate you taking the time to come on.
Oh, thank you. It was great being here.
It's been my pleasure. Thanks again. Thanks for taking the
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