Lynn Nanos’s book Breakdown paints a bleak picture of the mental health system. Specifically, the book is based on the author’s work in Massachusetts as an emergency psychiatric social worker or clinician working with ‘patients’ (Nanos, Breakdown) with extreme psychiatric diagnoses, i.e., psychosis or schizophrenia.
In the book’s introduction, Lynn states that the population she has worked with the most during her tenure as an emergency clinician is also, in fact, the most problematic. Lynn makes an argument for changing the mental health system in her state. In doing so, Lynn identifies long-standing access to treatment issues and the lack of parity between medical and psychiatric care.
The book makes these flawed aspects of the system visible to the reader regarding how insurance companies operate in the US, along with other issues of hierarchy within the medical profession and its impact on patient care and the shortage of psychiatrists in the country. Lynn’s book is dedicated to patients who have lost capacity. Lynn does not conceal her interest in working with the most impaired patients.
The book features cases with patients experiencing severe psychosis, complex fixed delusional systems, aggressive behaviors, and other complex symptoms. These issues impact the author’s ability to care for her patients, necessitating the call and need for a higher level of care. In most cases, these patients have already lost capacity and are at risk of serious imminent harm to themselves or others. While Nanos has no one specialty or specialization as an emergency clinician, her training and job responsibilities require her to have a broad skillset and compel her to work with diagnoses across the spectrum.
However, disorders like anxiety, depression, and other diagnoses with fewer complex symptoms are left absent from this book. Nanos indicates many people, in her experience, with these diagnoses are ‘higher functioning’ or at least have a more significant potential to be better advocates for themselves and be more adherent to their treatment.
Research on the correlation between diagnosis and adherence continues to be limited, and making such a claim may be problematic, as many patients who retain total capacity may also be poor advocates.
Nanos suggests her view of the system is narrow given her experiences as an emergency clinician working with the most extreme and troublesome cases across multiple systems intersecting the provision of mental health treatment. The book aims to raise awareness of the defects inhibiting patients from receiving adequate care, specifically inpatient treatment, by converting their rights to involuntary status.
Lynn clarifies that these are the patients who have lost all capacity and require involuntary inpatient treatment. Nanos states that the goal is to empower the legislature to make the necessary changes across systems and provide ‘comfort and validation’ to family and friends of severally mentally ill patients.
Mental health treatment, social work, psychology, and the allied fields are rich with acronyms. This book references many of them, several specific to the state of Massachusetts. However, any clinician will be able to decipher the more explicit references to programs and liken them to more significant levels of care. In this sense, the case vignettes are accessible, well written, dramatic, vivid, and at times, extremely disturbing for those who do not work with complex traumas and forensic cases.
Each vignette raises profound realities of the limits of the system in Massachusetts and states with similar laws surrounding mental health treatment, the conversion of patients’ rights from voluntary to involuntary status to ensure their safety, and the welfare of others in the community.
In no uncertain terms, the book takes a hard-line stance on the need for what so many refer to as forced treatment. Lynn does not negotiate a few complexities which are left conspicuously absent from the text. Nanos indicates such cases – substance abuse or illicit drug use and the children’s mental health system- are not included in the case examples. Given the diagnostic problems generally associated with working with drug abusers, concurring disorders, and working with children, vignettes including these cases are left absent from the book.
People with a dual diagnosis, MICA (Mentally Ill and Chemically Addicted), or co-occurring disorders among patients who have severe psychosis is a large segment of the SMI population. This book offers little diagnostic advice and direction to clinicians seeking information on how to treat or even manage these disorders on a systems or clinical level.
Lynn’s Breakdown doesn’t evaluate the etiology of its patient’s disorders, which is even more problematic. The book offers clinical priority to questions surrounding the provision of care and treatment of people with severe psychosis and an emergent need for clinical intervention.
Ultimately, Breakdown achieves what it sets out to accomplish in the book. Lynn Nanos cites case examples of systematic failures in which patients were a danger to themselves or others. Their safety was in jeopardy if they were not provided emergency inpatient treatment, albeit involuntary.
At the root of it, these case examples, while vivid and telling of the extreme dysfunction in the system, are incredibly black and white. The models are far from the clinical grey area, often confusing which direction in the provision of patient care and treatment should move. When it comes to the superabundance of liminal psychosocial contexts related to this population, these cases offer little insight into their treatment or new avenues in how to proceed with negotiating the system for their rights and care.