Psychiatric Emergencies: Empowering Connections to De-escalate Aggression

The National Alliance on Mental Illness defines a mental health crisis as a “situation in which a person’s behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community” (2). Also, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Like a physical health crisis, a mental health crisis can be devastating for individuals, families and communities” (3). The emergency department (ED) provides acute treatment for both types of crises.

During the initial months of the COVID-19 pandemic in March of 2020, EDs became flooded with medical emergencies related to the virus. The surge in mental health–related emergencies subsequently emerged. Research suggests that the social isolation, fear of contagion, economic stress (such as job loss), and grief surrounding the death of loved ones have had a damaging impact on mental health. A cross-sectional study by Holland and colleagues (4), using data from the Centers for Disease Control and Prevention’s (CDC’s) National Syndromic Surveillance Program, found that ED visit rates for mental health conditions, suicide attempts, drug overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019. These increases in psychiatric emergencies after COVID-19 surges have affected young adults and racially and ethnically minoritized populations most significantly (5).

The general population in the United States and globally has experienced negative psychiatric consequences related to the pandemic. Health care and mental health care professionals are not immune to this trauma, and many surveys have suggested that health care “burnout” is at an all-time high (6). Workplace violence has also been on the rise. The CDC’s National Institute for Occupational Safety and Health reported that over 75% of the 25,000 workplace assaults that result in days away from work annually in the United States took place in hospitals and other health care and social services settings. For health care professionals, the ED is a high-risk setting for aggression. Staff collaborating with patients in acute psychiatric crisis are at risk for physical and emotional traumatic injury (7).

Psychiatrists are not typically the first professionals on the scene interacting with agitated patients experiencing a psychiatric emergency. Police and security personnel may have brought the patient to the ED and remain present to maintain staff safety. Nurses and other health care staff are also present. In this crisis setting, the potential for violence of the patient toward personnel or for the personnel to invoke coercive methods to quell the agitation, such as restraints and involuntary medication, is high. This level of intervention may be necessary to maintain patient and staff safety in some situations. However, increased emphasis and training is required to ensure that all ED staff have expertise in noncoercive methods to assist the patient in gaining control using trauma-informed skills (3). “Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible” (8). Although staff in hospital mental health care settings are routinely trained in de-escalation techniques, psychiatrists have often been “the prescribers” in the emergency care rather than actively, empathically, and collaboratively helping patients calm themselves (9). The psychiatrist may be in the best position to evaluate the probable causes of the agitation, such as trauma, panic, substance use, psychosis, or other medical or behavioral issues.

Trauma-informed care is an essential element of crisis treatment. SAMHSA (3) set guiding principles for trauma-informed care. They include safety for patient and staff; trustworthiness and transparency; peer support and mutual self-help; collaboration and mutuality; empowerment, voice, and choice; and ensuring that cultural, historical, and gender considerations inform the care provided. The issues of implicit bias must be considered with each encounter. A systematic review found that health care professionals tend to associate Black patients with being less cooperative, compliant, and responsible in comparison with White patients (10). Another study reported that clinicians tend to associate Hispanic patients with medical noncompliance and partaking in risky behaviors (11). Research also indicates that racial disparities are present in the decision to restrain a patient. Black patients are more likely to be restrained while in the ED, even when controlling for confounding variables, such as diagnosis, sex, age, homelessness, and violence (12, 13). Trauma-informed best practices include attention to this potential bias each time an agitated patient presents to the ED.

Richmond and colleagues (8) proposed a three-step approach to de-escalation. First, the patient is verbally engaged; then, a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. The professional who is leading the de-escalating intervention requires ample time, self-composure, and team leadership skills to calm all involved.