The book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, deals with the involuntary commitment of people who experience schizophrenia, psychosis, some mood disorders, and anosognosia (lack of understanding or awareness of one’s own mental condition). Nanos lays out her thesis logically yet compassionately, with lots of references to back up her opinions.
What Nanos says is that involuntary commitment should be more widely available and easier to accomplish. Her experience as a clinician in Massachusetts involved many instances when she was involved with administering “Section 12” orders for involuntary commitment.
I’ll confess my bias up front. I’ve always been leery of involuntary commitment. As a person with bipolar disorder which was long untreated and un- or misdiagnosed, I have suffered with the fear that I might be committed at some point in my life. I’m a great believer in civil rights and believe that patients should have the right to refuse treatment.
Nanos is changing my mind, at least in the case of psychiatric disorders which prevent victims from knowing their own needs and taking care of themselves. She makes an excellent case that schizophrenic and psychotic patients, especially those with anosognosia, are the most likely of all psychiatric patients to commit violence and be victims of violence. This she refers to as “dying with their rights on,” a powerful phrase.
As it currently works – or doesn’t – forced commitment often leads to a revolving door of hospital emergency department stays, early release from psychiatric units, and the patients who most need help being discriminated against by psych units that turn them away because of their potential for violence and the difficulty in treating them. This results in homelessness, overuse of emergency services, release to relatives ill-equipped to handle a schizophrenic or psychotic person, and other potential dangers.
Nanos thoroughly discusses Assisted Outpatient Treatment (AOT) and other versions of court-ordered therapy and medication. Though these strategies are not without their flaws, Nanos indicates that her experience with them is that they are substantially beneficial and reduce violent behavior significantly.
Breakdown does not imply that there are simple or one-size-fits-all solutions to the serious problems with emergency psychiatry. The part insurance companies and hospitals play in not supplying adequate treatment is not ignored.
Lest one think that this is a dry, academic tome, though, Nanos fills the book with empathetic and sometimes searing stories of people that the system has failed – both patients themselves and the victims of their sometimes violent behavior.
How has Nanos’s book affected my opinions on involuntary commitment and related areas? The criteria she recommends for the procedure are far from superficial: She posits that involuntary commitment should be used only for those who are actively schizophrenic or psychotic and are unable to recognize the nature of their disorder and are unable to care for themselves – especially if they have shown signs of violent behavior or serious threats. (“Unable to care for self” takes the place of the older “danger to self” and includes conditions like homelessness, malnutrition, etc., not just being suicidal.)
Do I now think that involuntary commitment and/or AOT should be easier to accomplish? Yes, with the understanding that easier does not mean easy. We’re still talking about people’s civil rights, and those should not be broached with serious thought and safeguards in place. But my own fears of being involuntarily committed are revealed to have been irrational, a product of my bipolar disorder.
Has the psychiatric “system” broken down to the point where involuntary commitment is a necessary and even a beneficial thing? The answer, sadly, is yes. Lynn Nanos’s Breakdown has convinced me of that.