Bipolar Burble blog welcomes Lynn Nanos, a mobile emergency psychiatric social worker from Massachusetts. She writes about one patient’s experience with psychosis and the need for treatment without consent and assisted outpatient treatment (AOT).
I evaluate many patients with serious mental illness who lack awareness of being ill. Those who don’t understand they are ill, those who don’t have insight, are unlikely to initiate outpatient treatment. Here’s a story of one man who needed treatment without consent for his own safety.
A Story of Treatment Without Consent Needed
Tom,* a 30-year-old man, had been at the train station most of the morning. Police officers had grown concerned because he had refused to leave at midnight when it closed. After they forcibly removed him, he slept under a nearby bridge in freezing weather, wearing only jeans and a short-sleeved shirt.
When he returned to the station, officers noticed he was talking aloud to himself and not understanding that he didn’t belong there. They asked the crisis intervention team (CIT) police for help. (Crisis intervention team police have taken a 40-hour course on mental health.) Police from the CIT requested my help, and I went to the station to evaluate Tom.
The police introduced me to Tom, and I expressed my intention to help him.
He was malodorous, and his clothes and backpack were filthy. It seemed he hadn’t showered in days or weeks. He intensely stared at me and yelled, “You’re part of the problem! They sent you here to interfere with my work.”
“Who are you referring to?” I asked.
As he rapidly paced, he said, “You know.”
“What type of work?”
Tom told me the Federal Bureau of Investigation (FBI) gave him the authority to prevent a bomb from being planted on a train that could kill hundreds of people. Only he could deactivate it. He was still pacing back and forth and was clearly agitated.
“You are here to halt the mission! I know it!” he said.
I showed him my work badge with my photo ID and tried to reassure him that I worked for the crisis team.
“It’s a fake,” he said.
I asked him what season we were in.
Rather than answer me, he mumbled quietly to himself as he continued pacing.
Tom suddenly used his finger to trace an invisible box in the air.
“What are you doing with your hand?” I asked.
His eyes looked beyond and above me, as if I wasn’t there. He picked up his backpack from the floor, and began walking away from the police officers and me.
The CIT police officer interjected, “Tom, hold on please. We are trying to help you. Please allow Lynn to help you.”
“I don’t need any help! I’m good,” he said
I had to act quickly and authorize involuntary transport to the hospital. Walking by the other CIT officer, I whispered, “I’m going to write the Section 12.”
I walked a few feet away, out of his view, and filled out the Section 12. As I was about to sign it, I heard Tom screaming and yelling to “get off of me!”
They must have hand-cuffed him. I signed it and briskly walked to follow the yelling. They escorted him hand-cuffed to the entrance of the station where the ambulance soon arrived.
Two ambulance crew staff rolled a stretcher to the scene. I gave the Section 12 to them after an officer took a photo of it. At that point, there were six police officers there. Realizing that he would have to lie on his back on the stretcher, an officer freed him from the handcuffs as one of the CIT officers said to Tom, “We need for you to get on the stretcher and go to the hospital.”
“I’m not going anywhere. I have to work,” Tom said.
I told him, “We’re concerned you’re not acting like your usual self and we want you to get some help at the hospital.”
He glared at me, “I knew you were part of the plot!”
The officers and I spent five minutes trying to persuade Tom to get onto the stretcher, but he refused.
Finally, the CIT officer said, “I don’t want to restrain you.”
All eight of them manually restrained him on the stretcher as he yelled to “get off of me!”
He thrashed restlessly, trying to break free from the restraints to no avail.
When I got back to office to start typing up my report and contact insurance to request inpatient authorization, I noticed contact information for Tom’s brother in a recent mobile crisis record. I reached out to the brother, James, and updated him. James was relieved to hear that Tom was safe and on his way to inpatient because he hadn’t known where he was for about two months since he was previously hospitalized. James expressed concern that “they’re just going to release him to the streets without help again. That’s what they always do. Sometimes they never even contact me.”
I empathized with him and urged him to call the attending physician at the hospital to emphasize how urgently Tom needed inpatient care. This would increase the chances of them not releasing him prematurely. James said he’ll do this and thanked me. Then James told me he was “doing okay” about a year ago on a long-acting injectable antipsychotic prescribed by an inpatient doctor, but Tom refused to continue receiving this once released.
Treatment Without Consent and AOT Help Those with a Lack of Mental Illness Awareness
And while assisted outpatient treatment (AOT) would have helped Tom, it wasn’t used. Instead, Tom was caught in the revolving door of homelessness, police intervention, and hospitalization because of a lack of awareness about his own illness.
Assisted outpatient treatment helps people with serious mental illness who aren’t taking their medications due to their lack of awareness of being ill. It is mandated outpatient treatment for people who have a history of medication noncompliance, as a condition of their remaining outside of inpatient units. Research uniformly shows that AOT reduces rates of homelessness, incarcerations, violence, poor self-care, and hospitalizations.
Advocating for Treatment Without Consent and AOT
Most states and Washington, D.C. have AOT laws, but AOT is widely underutilized throughout the United States. Some states which allow it, such as PA, never use it. Massachusetts, Maryland, and Connecticut have no AOT. Advocacy efforts can be simple and effective. Place phone calls or mail letters to your legislators. Meet with them in real-time. Mail copies of my book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, to them. Prepare to testify at your State House. Change within the system is more likely to occur when concerned citizens pressure the government for it.
* Name changed for privacy reasons.
About the Author
Lynn Nanos is the award-winning and best-selling author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry. She is a licensed independent clinical social worker in her thirteenth year as a full-time mobile emergency psychiatric clinician in Massachusetts. She is an active member of the National Shattering Silence Coalition that advocates for the seriously mentally ill population. Find Lynn on her website.