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Sunday, February 25, 2018

Analysis of a Catastrophe

On Wednesday, February 14, 2018, nineteen years old Nikolas Cruz used a semiautomatic rifle to kill seventeen people, mostly teenagers at Marjory Stoneham Douglas High School. Cruz’s violent actions were so beyond the realm of normal behavior that many, including myself, assume that he was mentally ill at the time. Untreated seriously mentally people are more likely to be violent than the general population.

What was the extent of his mental illness? What can legislators do to try to prevent a recurrence? Should they tighten gun control or reduce mental illness? Although Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry will not address the gun control debate, the most thorough examination of mental illness should include it.

In One Source. One Organ posted on October 1, 2017, I wrote: “Even features of antisocial personality disorder, such as lack of empathy, are physically evident in the brain.” After a homicidal man told me about his enjoyment of killing small animals and his lack of remorse for harming others, I authorized his involuntary transfer to the hospital. He had a specific plan, means, and target in mind. He also killed people in the past. Later, the hospital emergency physician released him to a homeless shelter and told me that antisocial personality disorder didn’t rise to the level of inpatient criteria.

As a mobile psychiatric emergency clinician, I decide on a daily basis whether or not to authorize involuntary transfers of mentally ill patients to the hospital. I examine all the information available to me and ask myself if anyone will die if containment is not arranged. If Cruz landed on my caseload, what would I have done?

Let’s suppose that a family member brought to my attention that Cruz cut his arm on Snapchat. What did he intend to do when he cut? How deep into the skin did he go? Where on the body did he cut? Close to a vein or artery? Or between the elbow and wrist? Was he alone when he did this?

The Federal Bureau of Investigation (FBI) reported that someone reported to them that his behavior was erratic. ( This alone is not specific enough to warrant commitment.

Snapchat showed that he wanted to buy a gun. ( He bought the gun legally.

Well over forty articles all show that Cruz said that demon voices instructed him to kill his peers. To be clear, if this were known before the shooting, he would have qualified for inpatient. It arose after the tragedy. I cannot conclude that he was psychotic because it is too vague. Religious patients told me that God talked to them, or that they should not have listened to the devil just before making poor choices. Cruz did not make this statement to a forensic clinician. He might have been asked this in a leading way. His developmental disability might have interfered with his ability to report information accurately. Young children who do not have the same intellectual capacity as most adults have are certainly not always reliable reporters. He might have intended to say that he chose to act violently. Delusions are associated more with violence than hallucinations are.

Another diagnosis might have been discovered if he was in treatment. He was out of mental health treatment for more than a year, despite professionals recommending that he receive treatment. He was diagnosed with mental illnesses that are not associated with violence - autism, attention-deficit and hyperactivity disorder, and depression. However, the lack of being in treatment becomes alarming when considering the following threats of violence.

His caretaker called 911 stating that he put a gun to his brother’s head and previously put a gun to his mother’s head. (

On January 5, 2018, the FBI was informed that he owned a gun. ( This alone was not enough to qualify for inpatient, but when placed in the following context, inpatient criteria was met. Someone called the FBI last month stating that Cruz intended to kill people, perhaps at school. ( According to the Department of Child and Family Services, he expressed a desire to kill people. (

Cruz threated to harm his peers at school. He was referred for a threat assessment by the school in January 2017. ( A teacher requested of the administration, social worker(s), and psychologist(s) that they meet with him and his caregivers to assess what mental health services can be recommended or if he needs to be hospitalized. Before getting expelled, he was not permitted to carry a backpack to school because of the threats he made toward other students.

Last year, someone notified the FBI that Cruz posted on YouTube “Im going to be a professional school shooter.” ( An FBI representative said that they could not identify the author. This doesn’t seem accurate to me. Rather than order a psychiatric evaluation, they chose to do nothing.

Public defender Melisa McNeill said that Cruz is remorseful. This alludes to the possibility of serious mental illness. An array of articles point to his killing of small animals. This refers to the possibility of antisocial personality disorder. Stating that mental illness is rarely the cause of mass shootings minimizes the extent of its role.

The system is not sophisticated enough to consistently identify and predict who is most at risk of murdering others. The National Rifle Association spokeswoman Dana Loesch voiced that mentally disturbed people shouldn't be allowed to purchase guns. As long as the mental health system is as dysfunctional as it is, the implementation of this feat would be impossible because persons' potential for imposing violence is not always apparent. Under federal law, people who have been involuntarily committed are not allowed to buy guns. This is not nearly enough to prevent another school massacre. Firstly, commitment standards are overly restrictive in most states, which makes it hard to hospitalize people. Secondly, even if a dangerous person gets involuntarily committed and released, there are so many guns available in the United States that he can easily obtain one illegally.

My personal opinion is that all common civilians should not be allowed to access guns with the capacity (e.g., fast-capacity magazines, bump stocks) to inflict the carnage seen at Virginia Polytechnic college, Sandy Hook elementary school, and Douglas high school. The states and countries with the strictest gun laws have the least deaths from guns. ( Approximately 99 percent of the world does not have anything akin to our second amendment. Antiquated and unnecessary, it is repeatedly used as an excuse for gun violence. Cruz's right to own a gun obliterated the rights of these children. The United States is the only country in the world that encompasses this conversation. It is not needed elsewhere.

When safety concerns are brought to my attention, and the patient denies these, reliability must be questioned. When hints and clues exist, what is not seen must be considered. Dig deeply to unmask the whole story. Trust your instincts. Talk to people who know the patient best.

Saturday, January 27, 2018

Evaluate, transfer, discharge. Repeat.

While the inpatient lengths of stay have declined since deinstitutionalization, the readmission rates to inpatient units have increased.* The revolving door in the mental health system refers to the rapid cycling of admissions and discharges to and from both inpatient units and hospital emergency departments, as well as to and from jails and prisons.

A police officer escorts to my office a twenty-nine years old man, Owen. The officer explains that a psychotherapist's office called the police for assistance to have Owen removed from their agency because he was verbally aggressive and disruptive, refusing to leave. Apparently, he was there attempting to participate in an initial intake appointment to receive therapy and medication.

The hair on his head and face is long and matted. Even though the weather is warm outside, he is wearing three jackets. I look down and notice he's wearing only one shoe.

I cannot understand what he’s trying to convey because he rambles quickly and incoherently. Eventually, he tells me that he was referred to this intake appointment by a hospital emergency department. Besides telling me that he could benefit from some psychotherapy for his mania, he has no other concern and desires no other treatment.

He allows me to call his mom, Martha, so I do. She tells me that Owen has been functioning at the level I see today for the last four years, at which time she's been trying to get him help to no avail. "They keep on discharging him with nothing. They keep telling me he can't be helped unless he wants to be helped. He can go for weeks without sleeping. He has not even a cent to his name! The police usually bring him to the hospital. They call me, I beg them to keep him, but instead, they just let him go. It’s the same thing over and over again. He was diagnosed with bipolar and has been unmedicated for the last four years.” 

Owen is clearly unable to meet the ordinary demands of life. He is unable to attend to his basic biological needs. He is unable to maintain normal relationships. He is unable to communicate normally. I tell his mother about my intention to arrange for his hospitalization. To her relief, she agrees but cautions "He knows what to say to get out. They always believe him."

I try to find Owen with a plan to gauge if he'd be willing to go to the hospital. He is gone. I fax the involuntary authorization, with his mother's address on it, to the police. Hours later after completing an additional case, the police tell me they never found him. 


A week later, I am walking in the hallway just outside my office, when I happen to see Owen speaking in a loud tone of voice, apparently arguing with a staff member.

"Is this the intake office for the outpatient department?" He still appears disoriented to the situation at hand, as he demands from me socks, shoes, a new apartment, and employment. I tell him that I cannot directly give these materials to him. Believing there is a moderate chance that he'll prematurely elope again from me, I quickly latch on to anything that could persuade him to allow me to interview him. I attempt to reassure him about my intentions to help him, by offering to help him investigate when and where his next outpatient appointment is, or if he even has one scheduled. 

He is more malodorous than he was last week. Following his train of thought is impossible. He is talking fast and excessively. I attempt to interrupt him numerous times to no avail, but he quickly interrupts me at every attempt. He is animated with restless body movements. He asks loudly, "What kind of fucking establishment are you running here? You're a joke," before vehemently listing the many reasons that I should have never been granted a master's degree. 

He mindlessly repeats my verbalizations. As I increasingly write notes, his agitation increases. He demands to read everything I write because of his belief that I'm writing lies about him. I stop writing. In the briefest silence imaginable surrounding his garrulousness, I ask if he hears any voice that may not sound real. He yells, "No!" Seemingly fifteen minutes later, he voicelessly utters words for a couple of seconds.

I offer him water and suggest that we briefly break so that I can consult with colleagues for advice. We agree to part, and he accepts water from me. I ask a colleague to watch him while I write up the involuntary hold out of his view, suspecting that he would likely elope if he sees me writing it. I fax it to the police. Almost whispering to prevent Owen from hearing me, I call the police and ask for their assistance. When I go to check on Owen, he is nowhere in sight.


A month later, I reassess him. Seeing patients with psychosis cycle through emergency departments repeatedly within months before they are moved on to inpatient units is expected.


*Appleby, L., et al. “Length of Inpatient Stay and Recidivism among Patients with Schizophrenia.” Psychiatric Services, vol. 47, no. 9, 1996, pp. 985–990, doi:10.1176/ps.47.9.985.; Appleby, L., et al. “Length of Stay and Recidivism in Schizophrenia: a Study of Public Psychiatric Hospital Patients.” American Journal of Psychiatry, vol. 150, no. 1, 1993, pp. 72–76, doi:10.1176/ajp.150.1.72.

Sunday, November 26, 2017

Stigma and Antipsychiatry

Stigma toward mental illness embodies the belief that mentally ill people caused their illness. It associates mental illness with shame, infamy, and disgrace. How much stigma toward mental illness exists? It’s difficult to measure. Organizations expected to advocate for the mentally ill population, including the National Alliance on Mental Illness (NAMI) (StigmaFree | NAMI: National Alliance on Mental Illness,, appear to overemphasize stigma as a problem. They portray it as a massive problem and urgently promote campaigns to eradicate it.

Toward the beginning of my career, I grew to believe that stigma was the greatest barrier to accessing sound mental health treatment. I didn’t realize then that I allowed myself to be influenced by the many campaigns against stigma that were advertised. Is stigma less problematic than what the media and certain organizations make it out to be? Is the extent of the stigma that they claim a myth? Although stigma associated with mental illness exists, it is apparently not the greatest barrier to accessing treatment.

The Recovery Learning Communities (RLC) are groups, largely dominated by peer specialists, throughout Massachusetts that endorse the belief that signs of psychosis are normal. Besides running frivolous reiki groups, they regularly lead groups for their members titled “Hearing Voices.” They advertise that “Hearing Voices groups do not pathologize the experience of hearing voices or experiencing other altered/extreme states. Instead, they ask “What does the experience mean to you?”" (“Western Mass RLC | Healing and Recovery Through Peer Support.” Calendar, Western Mass Recovery Learning Community, 8 Nov. 2017, To pathologize a human experience means to view it as abnormal or dysfunctional. Hearing voices that are not there is certainly not normal. Science proves this. If impressionable people aged in their early twenties experience auditory hallucinations that involve commands to kill themselves or others for the first time and attend these groups, the chances that they will seek out appropriate treatment are reduced when they learn that nothing abnormal is going on. For months in a row in 2017, Western Mass Recovery Learning Community has advertised their seminars, titled Coming Off Psych Drugs, that have taught and encouraged people to stop taking their prescribed psychiatric medication (Davidow, Sera. “Western Mass RLC | Healing and Recovery Through Peer Support.” Coming Off Psych Drugs, Western Mass Recovery Learning Community,

When they do not deny the existence of mental illness, RLC minimizes it. Minimizing mental illness is not far off from believing that it doesn’t exist. If prospective followers of the anti-psychiatry camp are not persuaded to believe that no mental illness exists, they might be influenced to minimize mental illness, which contributes to stigma.

The government allows the belief that mental illness does not exist to infiltrate them. Massachusetts’ Department of Mental Health funds RLC (United States. Executive Office of Health and Human Services. Department of Mental Health. Search Results. Commonwealth of Massachusetts, 2017. NAMI's Massachusetts chapter promotes RLC (“PEER SUPPORT RESOURCES.” Peer Support Resources | NAMI Massachusetts, National Alliance on Mental Illness,

Saturday, October 28, 2017

Dangerously Unaware

When I started working on an inpatient psychiatric unit as a social work intern for the New York state's Office of Mental Health in 1996, my supervisor told me, "No one here is mentally ill." She was never part of the anti-psychiatry group who believe that mental illness doesn't exist. By stating this, she meant that many of these patients didn't believe that they were ill.

Psychiatric emergency services work can be akin to watching a train wreck without any ability to prevent the wreck from happening. When will the next tragedy involving serious injury or loss of life due to untreated serious mental illness occur? Governments are reactive.

The severe shortage of inpatient psychiatric beds along with overly restrictive inpatient commitment criteria often result in only the sickest of the sick getting admitted to inpatient units. For people with psychosis who lack awareness of being psychotic, brain deterioration often occurs long before sufficient psychiatric treatment is obtained. Early psychosis programs are completely voluntary, thus marginalize those who refuse to engage in treatment because they don't believe that they are ill.

I go to a psychotic woman's apartment with an outpatient worker because she stopped eating. She stopped eating because of her belief that people are poisoning her food. Because she believes that poisonous gas is coming out of her heating vents, she covers these. Because she believes that poisonous gas is coming out of her faucets, she keeps the water running continuously. She believes that running the water blocks the gas. As we are standing in water inches deep, she tells me that she is not mentally ill. Therefore, from her perspective there's no need to take any medication. The police are called and an ambulance transports her to the hospital emergency department. The emergency medical doctor calls and tells me that because she is well groomed, speaking clearly, not suicidal, and not homicidal, she is being discharged back to her home. Everything I report to them is disregarded. I'm just a social worker. Would she be moved on to inpatient if I am a psychiatrist or medical director of an agency? Would she be moved on to inpatient if she has a family member to advocate for her? Weeks later, she is evicted from her apartment with nowhere to sleep except for the streets.

A psychotic man got discharged from Bridgewater state "hospital," really managed by the Department of Correction, earlier that week. He was there because he was eating his feces and cutting himself to remove what he believed was the devil from his body while incarcerated. He yells out his fears of the devil when I evaluate him at the state-funded respite unit. He tells me that he got sentenced to prison because he pointed a loaded gun toward a stranger. I inquire about what made him do this. He says that the devil told him to do it. He doesn't believe that he is mentally ill.

Emergency medical doctors are more likely to discharge to the streets a dangerous patient who is not wanting any treatment, than a dangerous patient who is wanting treatment. They are more likely to move on to inpatient the malingerer who doesn't need treatment, than a psychotic patient who can "pull it together," and cover up symptoms. 

Sunday, October 1, 2017

One Source. One Organ.

One of the most challenging cases I ever managed involved sending a patient with antisocial personality disorder to the hospital emergency department involuntarily because he was actively homicidal with an intention, a plan, and a means to kill a targeted peer in the homeless shelter. I could barely identify any other mental abnormality in his clinical presentation. In making the decision to authorize his involuntary transport to the hospital, I used past knowledge, weighed various options and probable outcomes, and reflected on how to promote the safety of all involved.

Within a couple of hours later, I was challenged by the hospital emergency medical doctor there, who told me that antisocial personality disorder was not enough of a mental illness to warrant any treatment. This doctor then discharged him to the homeless shelter. Personality disorders are considered minor mental disorders, deemed not serious by official regulatory and authoritative standards. So was I expected to send him off to the homeless shelter to kill this peer?

Toward the end of February of this year, I wrote a blog here about the importance of language when referring to recipients of psychiatric treatment services. I argued that using terms besides "patients" when referring to them gives “psychiatry a pseudo-scientific appearance and undermines positive progress.” I went on with “For decades, psychiatry has had a reputation in the medical community as being less than medical, or even unworthy of respect in some instances. Psychiatry and its strides, albeit slower to come by than other medical disciplines, does not deserve a pseudo-scientific reputation.”

whereby they educate the public about mental illness in a section titled “Mental Health Conditions.” As I saw the many instances in which they use the word “condition,” I thought about how mental illness should not be referred to as a “condition.” Many advocates for the seriously mentally ill population oppose NAMI’s use of the word “condition” because it softens the illness. I agree that the term “illness” appears stronger than “condition,” and thus more indicative of pathology than “condition.” Describing mental illness as a “disease” is even better.

According to a dictionary, “A medical problem or illness can be referred to as a condition.” Did NAMI get it right? Or, did this dictionary get it wrong?

More relevant definitions:

  • Mental = pertaining to the mind. 

  • Mind = capacity to feel, think, perceive, and reason.

  • The literal definition of “psychology” and “psychiatry” is the study of the soul, rooted in the Greek word for “soul,” that is, “psi-chi.”

  • Soul = feelings, thoughts, behaviors that are typically considered as separate from the physical body. Some religions view this as immortal.

Psychiatry and neurology separated because mental disorders could not be attributed to any physical evidence. Hence neurology took over the study of pathology that was tangible, while psychiatry studied abnormalities that could not be seen. Despite the fact that the ability to feel, think, perceive and reason originates in the brain, many dictionaries still define “mental” as unseen material.

Indeed using the term “mental illness” softens and minimizes the seriousness of brain abnormality. With a bit of guilt, I will consistently use the terms “mental illness” and “mental health” throughout my book. I apologize for this. The reason for sticking to these terms is simple. These terms are so deeply ingrained into the fabric of my professional work and its surrounding field, that not using these terms would draw less of an audience.  

Technology has advanced to the point where schizophrenia, commonly known as a “mental illness,” is physically evident in magnetic scans of the brain. Even features of antisocial personality disorder, such as lack of empathy, are physically evident in the brain. I believe that psychiatry and neurology should merge and become one entire discipline. This would lessen or completely alleviate stigma toward "mental" illness.

Friday, September 1, 2017

Labor of Love

The most common question I get these days is, "When do you think your book will be published?" I have surpassed the halfway mark, and expect to have the first round of professional editing done by May of 2018. This is my first experience with writing a book. I have no past professional writing experience. I've never written an article for a newspaper, journal, or magazine. I've never blogged before these blogs. Deciding to write a book came about suddenly and unexpectedly.

After reading countless scholarly articles and non-fiction books relating to psychology and psychiatry as a hobby, I applied last year to a Doctorate of Psychology program in Massachusetts. My goal was to become a forensic psychologist. After the "enjoyment" (yes, that's sarcastic) of relearning algebra and geometry in preparation for the Graduate Record Examinations, I got as far as the interview. Then, I got rejected.

To the relief of many advocates for the population with serious mental illness, including myself, the federal 21st Century Cures Act passed toward the end of 2016. This monumental law restructures the Substance Abuse and Mental Health Services Administration, and vastly promotes Assisted Outpatient Treatment, along with many other great provisions that are way beyond the scope of this post. I will go into great detail about Assisted Outpatient Treatment in my book. At a glance, this helps a subset of the population with serious mental illness who are not adhering to their recommended outpatient treatment plans. It involves court ordered adherence to outpatient treatment plans, without forcing medication upon anyone. Although the 21st Century Cures Act helps to normalize Assisted Outpatient Treatment and alleviate its controversy, Massachusetts is way behind the times. Refusing to embrace the massive research supporting its effectiveness, it is one of only four states in the United States that doesn't have a law supporting this life-saving treatment.

I realized that five full-time years of further graduate school would have been extraordinarily lengthy and unnecessary, considering the extent of professional experience that I have. Meanwhile, I was struggling to shake off the sense that something was missing within me professionally. We completed the advocacy work that supported the 21st Century Cures Act. Rather than finding another television series to follow, I completed an online writing course. I researched the difference between traditional publishing and self-publishing. I purchased writing software. I learned how to cite research, which was also "enjoyable." I began researching marketing techniques for books.

I've never wanted to become an administrator because of how much I've liked clinical work. But with this, it's nearly impossible to change the mental health system from within my place of employment. Writing a book about my professional experience satisfies my desire to influence change beyond my place of employment. With every session involving work on my book, this void gradually lessens. It's a labor of love. 

Saturday, July 22, 2017


July 17th, 2017 - 

I arrive at the Boston State House in the morning with two copies of my prepared testimony in hand. One is to submit. The other is to read aloud.  

I expect there will be lots of waiting while hearing other testimonies since I testified on the same issue in 2013. As I wait, I hear mostly opposition to the Bill. They call themselves "survivors with lived experience." Instead of identifying mental illness as pathology originating from the brain, they berate psychiatrists for labeling people with psychiatric diagnoses. Instead of referring to auditory hallucinations as being a sign of mental illness, they promote the notion that hearing voices not there is simply an extreme state of altered reality (like "alternative facts"). Instead of indicating that psychosis is brain based, or that no one knows the cause of schizophrenia, one person who testifies expresses her belief that trauma caused her to become psychotic. Instead of pointing to the limitations of the Rogers authorization (enabling administering of medications forcibly) in the community, another person testifying says that the "Rogers monitor is already forced outpatient." Another one testifies that "forced medication is expensive and addictive." Instead of promoting the spread of respite programs that at least administer medications to very ill people (many of whom would otherwise not take these on their own), they request the creation of more peer run respites programs. Who are these people? To be a peer specialist, one must only have experience with being diagnosed with mental illness, or have been traumatized in some way, or have experienced what they refer to as "an extreme state." They encourage people with mental illness to stop taking their medications.* Sprinkles of the belief that mental illness doesn't exist runs amok throughout their teachings. 

The state government financially funds this group (including Reiki which has absolutely no scientific evidence showing it to be effective).** Sad, but true. 

To learn more about this group, please click on the following link: 
Article about this hearing from their perspective


My testimony: 

My name is Lynn Nanos. I am a Licensed Independent Clinical Social Worker with over 16 years of professional psychiatric inpatient and emergency experience in Massachusetts. I'm currently in emergency work. We shouldn't wait for the next tragedy due to lack of Assisted Outpatient Treatment (AOT). I have witnessed many cases in which people with psychosis have mentally deteriorated to such a deficient level that people have been harmed already. Allowing people with psychosis the right to further deteriorate in functioning is not liberating to anyone. Securing mental health treatment for someone who clearly needs this is not a violation of their rights.

Many of the people with psychosis whom I've professionally helped have had no awareness of their mental illnesses, which is called anosognosia. The majority of people with delusions whom I've evaluated have had anosogosia. Anosognosia is not willful. It involves abnormalities in the frontal and parietal lobes of the brain. All of the following cases involved anosognosia pertaining to psychosis.

A man with psychosis stopped complying with his antipsychotic medications immediately following his discharge from the inpatient unit I worked on. Police officers found that he jumped from the Tobin Bridge to his death within a month following discharge. He had been repeatedly admitted to this inpatient unit well over fifteen times during my years there.

A patient on my inpatient caseload who was paranoid delusional was refusing to accept medications. Shortly after getting discharged he killed his mother.

Between emergency evaluations, a man with psychosis who was not complying with his antipsychotic medications jumped off from a high rooftop to his death.

Police brought into my office a man who was yelling bizarre things on the streets. He was not able to provide a next of kin. He was planning to take the next bus to Washington DC because someone was ordering him to participate in the next presidential campaign. He was paranoid and explained that he's been ordered to kill anyone who tries to prevent him from getting on the next bus.

A person with psychosis and anosognosia cannot understand that treatment is needed. Appropriately timed treatment is more cost effective than lack of treatment. With AOT, admissions to inpatient units are more likely to be timely because its recipients have already been supervised by the outpatient system.

Outside of locked inpatient units, Rogers Monitors are meaningless and invisible. It's impossible to restrain and forcibly administer medications to an adult outside of a secured setting. Except for possibly secretly mixing medications in food, the only places where Rogers authorization have been implemented and enforced are locked inpatient units.

Many people with psychosis who refuse to voluntarily seek help end up incarcerated, which is more expensive than community-based treatment. AOT reduces the chances of arrests, incarcerations, hospitalizations, violence, and homelessness. For your review, I attached to this testimony evidence of the financial, and more importantly, the humane benefits to the majority of states in the United States, that have enacted AOT.

To learn more about the successful use of AOT in other states, please click on the following link: 
Attached statistics of benefits of using AOT in other states

*Iserman, Mitzi. “Western Mass RLC | Healing and Recovery Through Peer Support.” Coming Off Psych Drugs, Western Mass Recovery Learning Community, 28 July 2017, 
**United States, Executive Office of Health & Human Services. Department of Mental Health. Recovery Learning Communities. Commonwealth of Massachusetts, 2010.; “Recovery Learning Communities (RLCs).”, Transformation Center,