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A mental health crisis can be frightening and overwhelming – not only for the individual in crisis but their caretakers and loved ones too.  Knowing ways to de-escalate a situation before it gets completely out of hand and require a more intensive remedy is beneficial for all. 

Mental health crises occur as a result of an individual’s inability to cope. Many things can lead to a mental health crisis – such as a loss of a loved one, victimization, trauma or violence in home or community, school stressors, substance abuse, etc.   Children often do not know how to express themselves and cannot communicate their thoughts, feelings or emotions clearly, while adults in crisis often become too overwhelmed and are unable to seek help. Knowing what to do in times of high stress and having the support system to aid one with coping can make all the difference to one’s overall well-being.

With any crisis, there should always be a plan in place should one require immediate care.  Emergency rooms are usually the first place one may think of receiving help in the midst of a crisis. However, the thought of having to sit in a waiting room for hours at a time can be very discouraging and may spark a further crisis.

Schlicher and Haddock (2013)state that the number of psychiatric hospitals and acute care psychiatric units has declined steadily since the 1960s. Reasons for such shortages include the long-term effects of deinstitutionalization, inadequate community resources, the large numbers of uninsured patients, among other factors.  In the 1970s there were approximately 400,000 psychiatric beds available, compared to a low of just 50,000 in 2006, with 80% of states reporting a shortage of psychiatric beds. Consequently, wait times for psychiatric patients in an emergency room are the longest, with a wait time ofat least 48 hours (Nutt, 2016).

Another big problem in emergency rooms for psychiatric patients is boarding, described as “psychiatric patients waiting in hallways or other emergency room areas for inpatient beds.” (Alakeson, Ludwig & Pande, 2010).  Many emergency rooms are poorly equipped to deal with mental health needs or provide high-quality care there. Instead, boarded patients become a hindrance on staff since they are not seen as “real emergencies” and therefore affect the care of other patients.  Psychiatric patients’ overuse of and boarding in emergency rooms are symptoms of a lack of appropriate care stemming from a severe crisis in the mental health system (Alakeson, Ludwig & Pande, 2010).

Despite this, the number of patients in psychiatric crises’ presenting to emergency rooms is on the rise. Based on a study of a national database of emergency room visits, conducted by Hsia and colleagues, it was determined that psychiatric visits to the emergency room increased by 55% between 2002 and 2011, from 4.4 million to 6.8 million (Nutt, 2016).Furthermore, thephysical settings of an emergency room may not be the most supportive for those in a mental health crisis.  Factors such as noise level, being surrounded by individuals in pain or needing life-saving interventions, and access to instruments that can serve as a lethal means for patients that are suicidal, make the emergency room setting unconducive for psychiatric patients.

Several years ago, KidsPeace began offering walk-in appointments at their outpatient facilities as an alternative to visiting an emergency room.  The clinics are structured as urgent care walk-in models, allowing KidsPeace staff to be responsive to the immediate needs of the community. By offering this service, KidsPeace expedites the process of initiating care, avoiding long emergency room waits and allowing KidsPeace staff to assess each client’s individual needs and make an appropriate level of care recommendation. 

When individuals come to the walk in clinics they are in crisis mode.  For example, a referral may come from a guidance counselor saying that a child has made suicidal statements.  The child is then set up for a walk-in session at an outpatient facility to be assessed by a master’s level clinician.  Prior to the client arriving, the staff begin to prepare the process for a possible in-patient hospitalization.  Staff collaborate with KidsPeace Children’s Hospital and begin taking the steps necessary to admit a patient directly, thereby shortening the amount of wait time that the patient would otherwise spend dormant in an emergency room.

During the assessment, staff are assessing the level of crisis.  Many of the clinicians at KidsPeace are certified in Life Space Crisis Intervention (LSCI), an intervention that assists clinicians with turning crisis situations into learning opportunities.  Throughout the assessment process, families and individuals are being listened to, their questions are being answered and things are being explained in a way they can understand.  Psychoeducation is being provided to help them understand their situation better.  Precipitating factors of incidences are being explored: Did the client fail an exam? Are they having relationship problems? Family problems?  Often acknowledging the truth of their distress, allowing them to express their feelings, and providing reframes and statements of hope allow an individual to have a change in perspective and de-escalate.

Once the assessment is complete KidsPeace staff make the appropriate recommendation and instructions for aftercare and/or safety plan are discussed. Often individuals and families are not aware of the least restrictive options available to them in the community – such as social service agencies, wellness programs, in-home treatment, outpatient treatment, behavioral health rehabilitative services, acute partial hospitalization, etc.  Becoming aware of the support available right in one’s community often provides a sense of hope and helps with the de-escalation process. At KidsPeace, providing a continuum of care is essential to ensure individuals and families are treated with dignity and respect at all levels of treatment. 

In a survey conducted by NAMI (National Alliance on Mental Illness), patients shared what they thought were important to them receiving assistance during a crisis in an emergency room:

“(Sitting in) the waiting area when you are in crisis is the most difficult part. Until you are taken back to a room, it can be very difficult to cope with all of the things happening (around you).”

“The staff’s ability to communicate and listen to individual concerns were important factors.” (Duewel, 2015) 

At KidsPeace the vision is to transform lives of individuals with emotional, mental, developmental, and behavioral disorders caused by trauma, abuse, neglect or other causes; by providing mental health care and educational services in a safe environment with teamwork, compassion and innovation. A parent stated, “I know where I can find help now and that has made me feel better.”  A patient stated, “The staff were friendly, kind and caring and helped calm me during my crisis.”

Services meeting the clinical and personal need of patients make achieving safe and humane mental health treatment in the community possible.  Walk-ins have proven to be an effective way to do just that.

References

Alakeson, V. Ludwig, M., & Pande, N. (September 2010). A Plan to Reduce Emergency Room ‘Boarding’ of Psychiatric Patients Health Affairs Vol. 29, No. 9:
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2009.0336

Duewel, C. (June 5, 2015). Compassionate Care in the Emergency Room. National
Alliance on Mental Illness (NAMI). Retrieved from
https://www.nami.org/blogs/ nami-blog/june-2015/compassionate-care-in-the-emergency-room

Haddock, A. & Schlicher, N.R (2013). Mental Health in the Emergency Department.
Emergency Medicine Advocacy Handbook- Chapter 23; Section 27 of 35.
Retrieved from
https://www.emra.org/books/advocacy-handbook/chapter-23- mental-health-in-the-ed/

Nutt, A. E. (October 18, 2016). Psychiatric patients wait the longest in emergency rooms,
survey rooms, survey shows. The Washington Post.Retrieved from
https://www. washingtonpost.com/news/to-your-health/wp/2016/10/18/sickest-psychiatric-patients-wait-the-longest-in-emergency-rooms-survey-hows

Maria DeJesus-DeJesus-Perez, LSW

Maria DeJesus-DeJesus-Perez, LSW

Maria DeJesus-Perez, M.Ed, MSW, LSW is the Senior Clinician for KidsPeace’s Tobyhanna Outpatient program, overseeing and coordinating clinical services offered to assigned clients, including the provision of individual, group and family therapy.