Handbook of Emergency Psychiatry for Clinical Administrators

Gail M. Barton, Rohn S. Friedman, Gail M. Barton, Rohn S. Friedman

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138324848
• eBook ISBN: 9780429834318
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Originally published in 1986, this volume presents the clinical and administrative aspects of emergency psychiatry from the point of view of the clinician administrator involved in organizing and running an emergency service. Part 1 provides an administrative overview of psychiatric emergency care – the development of the field, the concepts, the patient profile, the team, the architecture, fiscal planning, legal constraints as well as training and research issues. Part 2 describes psychiatric emergency care delivery systems in the emergency department, the average hospital wards, the community mental health centers and health maintenance organizations. Part 3 gives examples of the process of administration – in one instance how a psychiatric emergency service developed, in the other how one functions day to day and what themes recur administratively. Part 4 focuses on protocols and models useful to the emergency service administrator: protocols, records, standards of care, politics, liaison with the court, mobile response, collaborative arrangements and disaster preparedness. Part 5 provides an annotated bibliography which reviews and draws attention to the relevant literature for the clinicians and administrators to use in practicing emergency psychiatry.

Part I

Administrative Concepts of Emergency Psychiatry

Chapter 1

The Development of Emergency Psychiatry

Rohn S. Friedman
Stephen Soreff
Gail M. Barton

Emergencies have always existed for psychiatry, but the health care community has not always provided psychiatry for emergencies. Until recently, treatment providers for psychiatric emergencies were most frequently families and police, and the most typical responses were either hospitalization or no treatment at all. In the last 25 years, a new concept of a psychiatric emergency care system has developed under the pressure of four major forces: technologic advance, deinstitutionalization, the community mental health center movement, and the emergency medical service system.

TECHNOLOGIC ADVANCE

Technologic advances in the field of emergency psychiatry include pharmacologic and psychologic interventions. The appearance of chlorpromazine in the 1950s made rapid control of acute psychotic symptoms possible. As experience showed that flagrant hallucinations, delusions, and thought disorders could be modified quickly, alternatives to long hospitalization could be considered. Minor tranquilizers and antidepressants appeared in the 1950s and 1960s, and by 1970 lithium was entering the field. Not all of these medications provided the same rapid response that the antipsychotic drugs did, but they did offer the potential of definitive treatment response within several weeks if the patient could be managed during that critical acute episode. Thus medications provided crisis treatment in some cases and in others created the possibility and need of utilizing other brief crisis intervention techniques while awaiting the definitive pharmacologic action of the drug.

Technologic improvements were not limited to drugs. New theory developed the idea that crises were part of normality, had a typical natural history and course, and could lead to growth as well as to catastrophe. Foremost in this work were Erich Lindemann’s studies of grief reactions, Gerald Caplan’s development of crisis theory, and Tyhurst’s work on disasters.^1,2,3 For all of these writers, crises were time-limited events that required the individual to make certain adjustments which could be facilitated by appropriate intervention. This development was met by another burgeoning field: family therapy. Nathan Ackerman, Virginia Satir, Jay Haley, Don Jackson, Gregory Bateson, Theodore Lidz, and others were involved in examining the role of the family in psychiatric illness.⁴ The emphasis on the family and the social context of illness led naturally to conceptualizing the family’s role in a crisis and to addressing the family in crisis intervention techniques.⁵ These new brief and rapid biological and psychosocial treatments expanded the therapeutic capacity to deal with emergencies.

DEINSTITUTIONALIZATION

Another force affecting the nature of emergency psychiatry has been the much discussed trend to deinstitutionalize chronic psychiatric patients.⁶ From a peak of 559,000 in 1955, the census of U.S. state mental hospitals has declined to 155,000 in 1980.⁷ More than 400,000 patients previously treated for long periods in state hospitals have been released into the community. These patients have enormous needs for social and psychiatric services, and they frequently present in crisis.⁸ Emergency services are called upon to deal with a population with severe mental illnesses and few resources, while communities are under pressure to create alternative programs and therapies for the chronically mentally ill.

Both the likelihood of admission and the average duration of hospitalization have decreased. At the same time outpatient resources are often unavailable, saturated, or underutilized due to patient non-compliance or lack of knowledge. It has largely fallen to emergency services to pick up the slack. Emergency services have had to expand as well as to develop new techniques to cope with this population and to provide more than a grudging revolving door into the inpatient ward.

COMMUNITY PSYCHIATRY

Technological advances and deinstitutionalization coincided with the 1960s political movement of community psychiatry which resulted in the nationwide system of community mental health centers. In 1961 the Joint Commission on Mental Illness and Health recommended comprehensive regional mental health clinics.⁹ Two years later the Community Mental Health Centers Act (PL 88–164) embodied the concepts of catchment areas, comprehensive mental health services and preventive psychiatry. The emphasis on preventive psychiatry, least-restrictive alternatives, and comprehensive programming led to the encouragement of a wide range of community services, including partial hospitalization programs, crisis units, hot lines, and family services. At the same time legislation mandated 24 hour emergency services among the five essential services of the CMHCs. Thus, a new array of local treatment options emerged with psychiatric emergency services in a prominent role.^10,11

EMERGENCY MEDICAL SERVICE SYSTEM

Emergency psychiatry did not appear in isolation. A complex emergency medical system was developing apace. In 1966 the Department of Transportation was authorized under the National Highway Safety Act to set guidelines for emergency medical services. This authorization led to the creation of the Emergency Medical Technician (EMT), later differentiated into EMT-A (ambulance) and EMT-P (paramedic) levels. EMT-paramedic training evolved to include standards for behavioral emergencies.¹²

In 1972 the Health Services and Mental Health Administration authorized five Emergency Medical Service (EMS) demonstration sites. Among other innovations, these sites were to integrate psychiatric services into their comprehensive medical services. The success of the demonstration sites resulted in the enactment in 1973 of the Emergency Medical Services Systems Act (PL 93–134), which provided incentives to state and local governments to develop comprehensive emergency services. Behavioral emergencies were clearly designated as a critical part of these services. At the same time the Robert Wood Johnson Foundation provided $15 million from 1973 to 1977 to develop further regional emergency medical response systems and a communications network to support them.

In 1963 the American College of Emergency Physicians (ACEP) was established, and in 1970 the Emergency Department Nurses Association (EDNA) and Society for Critical Care Medicine were formed.

Psychiatric collaboration in handling emergency cases was an integral part of this evolution. The practice of emergency psychiatry began regularly to take place within the regional emergency medical services systems that orchestrate a community’s entire emergency response network, including telephone emergency numbers, police and fire departments, EMTs, and general hospital emergency rooms.

As medical causes of psychiatric emergencies—drugs, physical trauma, or medical illness—were increasingly recognized, and as psychiatric contributions to the care of medical emergencies in areas like patient noncompliance or competency to refuse emergency treatment were valued more and more, the integration of psychiatric services with emergency medical services in the EMS system has powerfully influenced the development of emergency psychiatry.^13-17

THE STATE OF THE ART

These four forces—technologic advances, deinstitutionalization, community psychiatry, and the emergency medical system—have resulted in a large-scale, diverse psychiatric emergency care system. General hospital emergency rooms, community mental health centers, free-standing clinics, academic centers, and private clinicians are all part of the system within which clinicians from multiple disciplines are addressing mental health emergencies daily with great skill and dedication.

Despite this clinical commitment, a complex emergency psychiatric care system has emerged piecemeal, without consistent administrative planning. The various scientific and political forces have left chaos in their wake. Services are poorly coordinated, resulting in gaps and overlaps. Training programs often assign low prestige to emergency rotations. Rarely does the administrative setup allow intensive evaluation and psychosocial intervention, even though such intervention can frequently lead to savings of time, money, and morbidity.¹⁸ A survey of leaders in the field of psychiatric emergency care services found that they considered the leading priorities for the field to be the establishment of standards for patient care, records, and personnel; the design of training programs; and the coordination of psychiatric emergency care with other medical and mental health services.¹⁹ A measure of uniformity and consistency is urgently needed.

This volume seeks to address these needs and to reexamine the psychiatric emergency care system from the perspective of the clinician-administrator seeking to consolidate and advance the state of the art. The emphasis is upon the administrative framework within which the highest standards of clinical care can be achieved. Special attention is focused upon the different settings within which emergencies are met and their unique demands. Model administrative guidelines and protocols and an annotated bibliography are provided.

It is our belief that it is time for a generation of explorers to give way to a generation of settlers. We hope that our efforts will advance this process of consolidation.

REFERENCES

1. Lindemann, E.: Symptomatology and Management of Acute Grief. Am J Psychiatry 101:141–148, 1944.

2. Tyhurst, J.: Individual Reactions to Community Disaster. Am J Psychiatry 107: 764, 1951.

3. Caplan, G.: Principles of Preventive Psychiatry. New York: Basic Books, 1964.

4. Ackerman, N.: The Psychodynamics of Family Life. New York: Basic Books, 1958.

5. Langsley, D. and Kaplan, D.: The Treatment of Families in Crisis. New York: Grune & Stratton, 1978.

6. Talbott, J.A. (ed): The Chronic Mental Patient. Washington, D.C.: American Psychiatric Association, 1978.

7. Bull, H.: State Hospitals Should Be Kept—For How Long? In Abbott, J.A. (ed): State Mental Hospitals. New York: Human Sciences Press, 1980.

8. Bassuk, E.L.: The Impact of Deinstitutionalization on the General Hospital Psychiatric Emergency Ward. Hosp Community Psychiatry 31: 623–627, 1980.

9. Joint Commission on Mental Illness and Health: Action for Mental Health. New York: Basic Books, 1961.

10. Spitz, L.: The Evolution of a Psychiatric Emergency Crisis Intervention Service in a Medical Emergency Room Setting. Compr Psychiatry 17: 99–113, 1976.

11. Braun, P., Kochansky, G., Shapiro, R., et al.: Overview of Deinstitutionalization of Psychiatric Patients: A Critical Review of Outcome Studies. Am J Psychiatry 138: 736–749, 1981.

12. Joint Review Committee on Educational Programs for EMT-Paramedics: Essentials of an Accredited Educational Program for the Emergency Medical Technician-Paramedic. Chicago: American Medical Association, 1978.

13. Jefferson, J.W., and Marshall, J.R.: Neuropsychiatry Features of Medical Disorders. New York: Plenum, 1981.

14. Hall, R.C.W. (ed): Psychiatric Presentations of Medical Illness. New York: SP Medical & Scientific Books, 1980.

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Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface: Gail M. Barton, MD, MPH Rohn S. Friedman, MD
• Contributors
• PART I: ADMINISTRATIVE CONCEPTS OF EMERGENCY PSYCHIATRY
• PART II: PSYCHIATRIC EMERGENCY CARE DELIVERY SYSTEMS
• PART III: EXAMPLES OF THE ADMINISTRATIVE PROCESS
• PART IV: PROTOCOLS AND MODELS FOR CLINICAL ADMINISTRATION
• PART V: BIBLIOGRAPHY
• Index