A TERM PAPER

ON

CRISIS MANAGEMENT IN PSYCHIATRY

JUNE, 2018.

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 INTRODUCTION

Caplan (1964) first defined a crisis as an event that occurs when individuals are confronted with
problems that cannot be solved resulting in increased tension, anxiety emotional unrest and
inability to function effectively for a long period of time. James and Gillard (2005) defined crisis
as an event or situation perceived as intolerably difficult that exceed an individual’s available
resources and coping mechanisms ( Dr Sunil Suthar: Slideshare; Crisis Intervention in
Psychiatry)

In the occurrence of crisis, the precipitating events are perceived as threatening, and there will be
apparent inability to modify or decrease the effect of the event. The patient’s fear will increase
and will be subjected to high level of discomfort. Events that can result in crisis include death of
loved one, divorce or separation, unexpected pregnancy, natural disaster, etc ( Dr Sunil Suthar:
Crisis Intervention in Psychiatry)

In psychiatry, crisis does not usually happen, but when it does, the health team must be ready to
act quickly in order to provide a solution, especially in life threatening situations. Crisis in
psychiatry can also be used interchangeably with psychiatry emergency because it usually ends
up in emergency. It proceeds gradually and if not alleviated will result in violence and life
threatening events. Patients may have suicidal attempts (Julie M Mroczek, Silvia Prodan Lange,
Meredith Patterson; National Center for Continuing Education Inc; Managing the Psychiatric
Crisis)

Everyone experiences personal crisis which may be acute, time-limited or experienced as

overwhelming emotional reaction to one’s perception of an occurrence. Crises are therefore self-
defined and environmentally based. When a person tries hardly enough to gain balance but is till
not able to, crisis sets in. the health management team needs to know when and how to intervene
in the occurrence of crises. The major goal of this team should include ensuring the safety and
emotional stability of the patient, avoiding further deterioration of the patient’s state, helping in
obtaining ongoing care for emotional crisis and ensuring that their practices and services are
clinically appropriate.

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 SIGNS OF CRISIS IN A PSYCHIATRIC PATIENT

When a patient is undergoing crisis, he or she begins to behave in some certain ways and react in
different ways, such that an observant health worker would know the patient’s situation. Such
behaviours could manifest physically, psychologically or interpersonally.

Physical Signs

1. The patient will always talk about committing suicide

2. The patient will cause self injury that usually does not require urgent or immediate
medical attention.
3. Extreme energy or lack of it, sleeping all the time, or being unable to sleep
4. Muscle tension, fatigue, sweaty palms
5. Increased vulnerability to cold and other communicable diseases.
6. Sleep disturbance
7. Shortness of breath
8. Severe agitation, pacing,
9. Talking very rapidly or non-stop

Psychological Signs

1. Emotional distress, depression, anger, anxiety and fear

2. Paranoia
3. Eating disorders
4. Alcohol or substance abuse

Interpersonal Signs

1. Increased arguments and isolation from people

2. Conflict with colleagues and caregivers
3. Domestic violence
4. Unusual behavior
5. Rapid mood swings

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6. Confused thinking or irrational thoughts
7. Thinking everyone is out to get individual or seeming to lose touch with reality
8. Experiencing hallucinations or delusions

TYPES OF CRISIS

1. Developmental (maturational) crisis: It is predicted times in everyone’s life which

occurs in response to a transition from one stage to another in the life cycle. A
maturational crisis is a stage in a person’s life where adjustment and adaptation to new
responsibilities and life patterns are necessary. The transition points where individuals
move into successive stage often generate disequilibrium. Individuals are required to
make cognitive and behavioural changes and to integrate those physical changes that
accompany development. The extent to which individuals experience success in the
mastery of these tasks depends on previous successes, availability of support systems and
influence of support systems and influence of role models and acceptability of new role
by others. The transitional periods or events that are most commonly identified as having
increased crisis potential are adolescence, marriage, parenthood, midlife and retirement.
Example: Erikson’s stages…..going from industry to identity.
2. Situational crisis: Occurs in response to a sudden unexpected event in a person’s life.
The critical life events revolve around experiences of grief and loss. A situational crisis is
one that is precipitated by an unanticipated stressful event that creates disequilibrium by
threatening one’s sense of biological, social or psychological integrity. For example, loss
of a job, divorce, abortion, death of a loved one, severe physical or mental illness,
premature birth, status and role changes, change in geographic location and poor
performance in school.
3. Adventitious crisis/Social crisis: Are not part of everyday lives. Social crisis is
accidental, uncommon, unplanned and unanticipated and results in multiple losses and
radial environment changes. Such as natural disasters(hurricanes, flood, fire, earthquake,
war,), riots, crime of violence, child abuse, rape, assault, bombing in crowded areas, etc.
Because of the severity of the effects of social crisis, coping strategies may not be
effective. Support systems may be unavailable because they may also be involved in

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similar situations. Mental health professionals are called upon to act quickly and provide
services to large numbers of people and in some cases, the whole community.

Baldwin(1978) identified 6 classes of emotional crises which progress by degree of

severity.
1. Class I; Dispositional crises:
An acute response to an external situational stressor.
2. Class II; Crises of anticipated life transitions.
Normal lifecycle transitions that may be anticipated but over which the individual
may feel a lack of control.
3. Class III; Crises resulting from traumatic stress.
Crises precipitated by unexpected external stresses over which the individual has
little or no control and from which he or she feels emotionally overwhelmed and
defeated.
4. Class IV; Maturational development crises.
Crises that occur in response to situations that trigger emotions related to
unresolved conflicts in one’s life. These crises are of internal origin and reflect
underlying developmental issues that involve dependency, value conflicts, sexual
identity, control, and capacity for emotional intimacy.
5. Class V; Crises reflecting psychopathology.
Emotional crises in which preexisting psychopathology have been instrumental
in precipitating the crisis or in which psychopathology significantly impairs or
complicates adaptive resolution. E.g Borderline personality, severe neuroses,
schizophrenia.
6. Class VI; Psychiatric Emergencies.
Crisis situations in which general functioning has been severely impaired and
the individual rendered incompetent or unable to assume personal responsibility. E.g
acutely suicidal individuals, drug overdoses, reaction to hallucinogenic drugs, acute
psychoses, uncontrollable anger and alcohol intoxication.

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 PHASES OF CRISIS

1. Phase I : The individual is exposed to a precipitating stressor. Anxiety increases, problem-

solving techniques are employed. Perceived threat acts as a precipitant that generates increased
anxiety and normal coping strategies are activated and if unsuccessful, the individual moves into
phase II.

2. Phase II: When previous problem solving techniques do not relieve the stressor; anxiety
increases further. The individual further feels a great deal of discomfort at this point. Coping
techniques that have worked in the past are attempted, only to create feelings of helplessness and
disorganization prevail. The individual experiences a sense of vulnerability. The individual may
attempt to cope with the situation in a random fashion. If the anxiety continues and there is no
reduction; the individual enters phase III.

3.Phase III: All possible resources, both internal and external, are called on to resolve the
problem and relieve the discomfort. The individual may try to view the problem from a different
perspective, or even to overlook certain aspects of it. New problem-solving techniques may be
used, and, if effectual, resolution may occur at this phase, with the individual returning to a
higher, a lower, or the previous level of pre-morbid functioning. If the problem solving is
unsuccessful, further disorganization occurs and the individual is said to have occurred.

4.Phase IV: If resolution does not occur in previous phases, Caplan states that “the tension
mounts beyond a further threshold or its burden increases over time to a breaking point. Major
disorganization of the individual with drastic results often occurs”. Anxiety may reach panic
levels. Cognitive functions are disordered, emotions are labile, and behavior may reflect the
presence of psychotic thinking.

CERTAIN CONDITIONS THAT CAN RESULT IN EMERGENY CRISIS

There are certain mental health conditions or life situations that can result in psychiatry crisis.
They include suicidal attempts or suicidal thoughts, aggression or violent behavior, grief, panic
attack, catatonic stupor, shock, hysterical attacks, situational disturbances,delirium tremens,

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epilepsy, acute drug-induced extrapyramidal syndrome, disaster, and rape. Few of these causes
will be discussed further in this paper.

SUICIDAL ATTEMPTS/ SUICIDAL THOUGHTS

Suicide is a type of deliberate self-harm and is the intentional act of killing oneself. It is one of
the commonest emergencies in psychiatry. The cause of suicide is unknown, however, there are
some situations or events that can make an individual attempt suicide. They include:

 major psychiatric illness - in particular, mood disorders (e.g., depression, bipolar

disorder, schizophrenia)
 substance abuse (primarily alcohol abuse)
 family history of suicide
 long term difficulties with relationships with friends and family
 losing hope or the will to live
 significant losses in a person's life, such as the death of a loved one, loss of an important
relationship, loss of employment or self-esteem
 unbearable emotional or physical pain

WARNING SIGNS OF IMPENDING SUICIDAL ATTEMPT

A person who is at risk of committing suicide usually shows signs whether consciously or
unconsciously that something is wrong. Keep an eye out for:

 signs of clinical depression

 suicidal threats
 withdrawal from friends and family
 sadness and hopelessness
 appearing peaceful and happy after a period of depression.
 lack of interest in previous activities, or in what is going on around them
 physical changes, such as lack of energy, different sleep patterns, change in weight or
appetite
 loss of self-esteem, negative comments about self-worth
 bringing up death or suicide in discussions or in writing
 previous suicide attempts
 getting personal affairs in order, such as giving away possessions, or having a pressing
interest in personal wills or life insurance, or writing farewell letters.

Though many people considering suicide seem sad, some mask their feelings with excessive
energy. Agitation, hyperactivity, and restlessness may indicate an underlying depression that is
being concealed.

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Many people believe that even though a person might talk about suicide, they will not actually
do it. In fact, talking about suicide is a warning sign that the person is at greater risk. If such
individual become so overwhelmed by problems that suicide becomes a consideration, (s)he
deserves to be taken seriously.

MANAGEMENT OF A PATIENT WHO IS AT RISK OF ATTEMPTING SUICIDE

1. The nurse should make sure to remove every harmful equipments (sharp, instruments,
clothes, belts, neckties) away from the patient’s environment.
2. The nurse must take every suicidal threat seriously and notify other members of the
health team.
3. The nurse must not leave the drug tray within the reach of the patient, and make sure to
remove any toxic drug the patient may possess.
4. The nurse should ensure that the patient does not lock the door from inside, and does not
go to the bathroom or secluded places alone.
5. The nurse should ensure constant observation of the patient and be very vigilant.
6. Speak with the patient, spend time with him/her and allow him/her to express his/her
mind.
7. Encourage him /her to talk about his/her suicidal palns.
8. Sedate patients when necessary (if the tendencies are severe)
9. Focus on the patient’s strengths in order to help him bring up his self-esteem.

If the patient has attempted suicide,

1. Assess airway and suction if necessary.

2. Assess for vital signs. If pulse is weak, start IV fluid.
3. If the patient dies in the suicide attempt, ensure all things necessary to take away the
body from the site ward.
4. Ensure that other patients are taken away from the site of incident and distracted with
other activities.
5. Inform the guardian/ relatives of the diseased.
6. Ensure proper documentation.

PANIC ATTACKS

This involves episodes of acute anxiety and panic. It may result from a psychotic or neurotic
illness. When this happens, the patient experiences palpitations, sweating, tremors, chest pain,
fear of dying, nausea, etc.

MANAGEMENT

1. Assure the patient and calm him down,

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 2. Find the cause(s) of the attack and remove it.
3. Administer sedative like diazepam or lorazepam.

AGGRESSION / VIOLENT BEHAVIOUR

Causes of violent and aggressive behaviours

A number of different factors converge to increase the likelihood of violent behavior. These
factors can be divided into roughly three groups: (1) innate factors; (2) socialization factors; and
(3) situational factors.

INNATE FACTORS

Beginning in the early part of the twentieth century, ethnologists saw aggression and violence as
a response to the call of internal mechanisms or instincts. This emphasis found good company in
the Freudian psychoanalysts. They saw aggression as derived from an inborn tendency to
destroy. Like all instincts, it builds up over time and must ultimately be discharged in either
acceptable or unacceptable ways.

SOCIALIZATION FACTORS

Socialization plays an important role in the temperament of an individual. Peer groups, social
media, family, and immediate environment all are socialization agents. The way things are with
these agents may either make or mar the individual’s temperament.

For example, reinforcement is a way of impacting a particular behaviour in an individual. A

young child wants a toy, but his playmate will not relinquish it. The boy pushes and grabs the toy
and the playmate relents. Aggression works. If followed by reinforcement, both mild aggression
and serious violence are likely to increase. In addition to the role of reinforcement, early
formulations of social learning theory emphasized the role of observational learning (Bandura).
Individuals who see others use and obtain rewards for violence, especially others whom they
admire, are more likely to imitate them and behave violently under similar circumstances.

Research has shown that parents can be a powerful force in shaping children's behavior. Lack of
attention to children's behavior and inconsistent parental discipline and monitoring of activities
have been consistently related to the development of aggressive and violent behavior patterns.

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Extremely harsh and abusive parenting has also been linked to later aggression. Stated simply,
"violence begets violence." Equally important is the failure of positive encouragement for
prosocial and nonviolent behaviors. Many parents ignore children's efforts at solving conflicts
peacefully or managing frustration. Oversights such as these may inadvertently teach children
that aggressive acts alone are worthy of notice.

Studies have shown that more aggressive and violent individuals have different ways of
processing information and thinking about social situations. They tend to interpret ambiguous
cues as hostile, think of fewer nonviolent options, and believe that aggression is more acceptable
(Crick and Dodge). Once these cognitions crystallize during socialization, they are more resistant
to change.

SITUATIONAL FACTORS

Situational catalysts can also lead to violence and increase the seriousness of such behavior.
Almost any aversive situation can provoke violence. Frustrating situations are linked to
heightened aggression, although frustration does not always produce aggression and is certainly
not the only instigating mechanism. Other aversive experiences such as pain, foul odors, smoke,
loud noises, crowding, alchohol and heat portend heightened aggressiveness, even when such
behavior cannot reduce or eliminate the aversive stimulation

MEDICAL CONDITIONS

Medical illness may result in behaviour disturbance. It can also coexist in patients with mental
health, drug and alcohol problems or other conditions .

Hypoxia, hypercarbia – pneumonia, worsening chronic airway disease

Hypoglycaemia – diabetes, malnourished alcoholic

Cerebral insult – stroke, tumour, seizure, encephalitis, meningitis, trauma

Sepsis – systemic sepsis, urine infection in the elderly

Metabolic disturbance – hyponatraemia, thiamine deficiency, hypercalcaemia

Organ failure – liver or renal failure

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Withdrawal – alcohol, benzodiazepines

Drug effects – amphetamine, steroids, alcohol, prescribed medications and interactions

Medical management of violent and aggressive behaviours

Pharmacological therapy

Careful diagnosis has to be made to avoid overuse and misuse of medication. Medications are
used primarily for 2 purposes-

i. To use sedating medication in an acute situation to calm the client so that client will not harm
self or others.

ii. To use medication to treat chronic aggressive behaviour.

often it is the sedating property of antipsychotic that produce the calming effect for the client.
Atypical antipsychotic are also commonly used. But only Ziprasidone is available in
intramuscular form.

i. Haloperidol-1 mg or 0.5 mg IM

ii. Risperidone o.5mg-1mg- In dementia and schizophrenia.

iii. Trazodone – 50-100mg . In older clients with sun downing syndrome and aggression.

iv. Benzodiazepines- used due to the sedative effect and rapid action. Most commonly
lorazepam, oral or injection. Other sedating agents used include Valproate, chloral hydrate and
diphenhydramine.

When client continues to exhibit aggression more than several weeks’ choice of medication is
based on underlying condition. I.e., if related to schizophrenia-antipsychotic.

i. Antipsychotic

ii. Anxiolytics- Buspirone

iii. Carbamazepine and valproate to treat bipolar associated aggressive behaviour.

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iv. Antidepressants –trazodone in aggression associated with organic mental disorder.

v. Antihypersensitive medication – Propanolol to treat aggression related to organic brain

syndrome.

Following assessment , if the patient is believed to be potentially violent, the nurse should:

a. Implement the appropriate clinical protocol to provide for the patient and staff safety

b. Notify co-workers

c. Obtain additional security if needed

d. Assess the environment and make necessary changes.

e. Notify the physician and assess the need for prn medications.

NURSING INTERVENTIONS

Nursing interventions can be thought of existing in a continuum . They range from preventive
strategies such as self awareness, patient education and assertiveness training to anticipatory
strategies such as verbal and nonverbal communications, and the use of medications. If the
patient’s aggressive behaviour escalates despite these actions the nurse may need to implement
crisis management techniques and containment strategies such as seclusion or restraints.

Patient education

Teaching patients about communication and the appropriate way to express anger can be one of
the most successful interventions in preventing aggressive behaviour.

Assertiveness training

Interpersonal frustration often escalates to aggressive behaviour because patients have not
mastered the assertive behaviours. Assertive behaviour is a basic interpersonal skill that includes
communicating directly with another person, saying no to unreasonable requests, being able to
state complaints.

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Patients with few assertive skills can learn them by participating in structured groups and
programmes . Staff can provide feedback to patients on appropriateness and effectiveness on
their responses.

Communication strategies: Nurses have to:

i. present a calm appearance

ii. speak softly

iii. speak in a non proactive and non judgemental manner

iv. speak in a neutral and concrete way put space between yourself and patient

v. show respect to the patient

vi. avoid intense direct eye contact

vii. Demonstrate control over the situation without assuming an overly authoritarian stance.

viii. Facilitate the patient’s stance.

ix. Listen to the patient

x. Avoid early interpretations

xi. Do not make promises that cannot keep.

xii. Avoid intense direct eye contact

xiii. Demonstrate control over the situation without assuming an overly authoritarian stance.

xiv. Facilitate the patient’s stance.

xv. Listen to the patient

xvi. Avoid early interpretations

xvii. Do not make promises that cannot keep.

Environmental strategies

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In-patient units that provide many productive activities reduce the chance of inappropriate
patient behaviour and increase adaptive social and leisure functioning. Both the unit norms and
the rewards associated with such activities may reduce the amount of disorganised patient
behaviour and the number of aggressive acts.

Aggressive behaviour is more effectively managed by allowing those at risk to spend time in
their rooms away from the hectic day room rather than encouraging them to interact with others
in a crowded milieu.

Behavioral strategies

Nursing interventions include applying principles of behaviour management to aggressive

patient.

 Limit setting
 Behavioral contracts :To be effective contracts require detailed information about:
 Unacceptable behaviours.
 Acceptable behaviours.
 Consequences for breaking the contact.
 The nurse’s contribution to care.
 Patients also should have input into the development of the contract to increase their
sense of self control.
 Time out
 Token economy: In this intervention, identified interpersonal skills and self care
behaviours are rewarded with tokens that can be used by the patient to buy items or
receive rewards or privileges. Behaviours to be targeted are specific to each patient.
guidelines has to be made for desired behaviours required to receive the tokens, the
number of tokens to be received for each behaviour and the length of time a desired
behaviour must be exhibited to receive tokens.
 Crisis Management
 Seclusion
 Restraints

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  Debriefing: Debriefing is an important part of terminating the use of seclusion or
restraints. Debriefing is a therapeutic intervention that includes reviewing the facts
related to an event and processing the response to them. It provides the staff and patient
with an opportunity to clarify the rational for seclusion, offer mutual feedback, and
identify alternative, methods of coping that might help the patient avoid seclusion in the
future.

MENTAL HEALTH CRISIS EMERGENCY MANAGEMENT

A mental health emergency is considered a life-threatening situation. The person is imminently

threatening harm to self or others, severely disoriented or out of touch with reality, functionally
disabled, or extremely distraught and out of control. Very often such aggressive, violent patients
are psychotic or have substance abuse issues, but it must never be assumed that the cause of the
behavior is a mental disorder or intoxication, including those patients known to have a
psychiatric disorder or an odor of alcohol on their breath.

During such emergency crises, management and evaluation must occur simultaneously. Often
these patients are unable or even unwilling to provide a clear history, and other sources must be
found and consulted as rapidly as possible. This might include family members, friends,
therapists or caseworkers, and medical records. Confidentiality is waived during psychiatric or
medical emergencies, allowing for collection of such collateral data (USDHHS, 2014).

When working with an agitated and/or aggressive person there are four main goals:

a. Ensure the safety of the patient, staff, and others in the area
b. Help the patient to manage emotions and distress and to regain and maintain control of
behavior
c. Avoid the use of restraints whenever possible
d. Avoid coercive interventions that can escalate agitation (Moore & Pfaff, 2017)

DE-ESCALATION

The first step in responding to mental health emergencies is to attempt de-escalation. This is key
to helping the patient become an active partner in evaluation and treatment. When a patient is

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unable to control emotions or behaviors, the following de-escalation techniques have been found
to be frequently successful in less than five minutes.

 Remove from stimuli. The physical environment can make a patient feel threatened
and/or vulnerable. Removal from a noisy environment to a quieter space helps reduce a
patient’s stress and frustration.
 Respect personal space. Remain two arms’-length distance from the patient and maintain
an unobstructed path out of the room for both the patient and staff.
 Set clear limits and expectations. Tell the patient that injury to self or others is
unacceptable and that violence or abuse cannot be tolerated.
 Minimize provocative behavior. It is important to remain calm and to speak in a calm
voice. Movements should be slow and actions should be announced prior to initiating
them. Avoid touching the person unless asking permission first.

Posture and behaviors can make a patient feel threatened and/or vulnerable so a calm demeanor
and facial expression should be maintained. Keep hands visible and unclenched, as concealed
hands might imply a hidden weapon. Avoid confrontational body language such as hands on
hips, arms crossed, directly facing the patient, and continuous eye contact.

 Establish verbal contact. If possible, the first person to contact the patient should be the
staff leader. Otherwise designate one or limited staff members to interact with the patient.
Introduce self and staff and orient the patient to the emergency department or facility and
what is to be expected. Reassure the patient that he or she will be helped. Recognize that
the person in the midst of a mental health crisis emergency may be unable to clearly
communicate thoughts, feelings, or emotions.
 Use concise and simple language. Agitated patients may be impaired in their ability to
process information. Repeating the message and allowing adequate time for the patient to
respond can be helpful.
 Use active listening skills. Identify feelings and desires. Listen attentively and empathize
with the person’s feelings. (See also “Communication Techniques” earlier in this course.)

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  Agree or agree to disagree. Use fogging, an empathic behavior in which one finds
something about the patient’s position upon which to agree. “Yes, I agree with what you
said.”
 Collaborate. Use a collaborative approach with the goal of helping the patient calm
him/herself.
 Offer choices and optimism. Realistic choices aid in empowering the patient to regain
control and feel like a partner in the process.
 Do not: Criticize the patient, Argue with the patient, Interrupt the patient, Respond
defensively, Take the patient’s anger personally, Lie to the patient, Make promises about
something that may not happen
 Debrief the patient and the staff. If an involuntary intervention is indicated, debriefing
may help restore the working relationship with the patient and help staff plan for possible
future interventions. Debriefing should involve an explanation as to why the intervention
was necessary, and the patient should be asked to explain his or her perspective of the
event. Options or alternative strategies should be discussed with the patient and with staff
should the situation arise again. (Moore & Pfaff, 2017; Chun et al., 2016)

De-escalation, when effective, can avoid the need to use restraints. It is important to remember
that taking the time to de-escalate the patient and working collaboratively as the patient settles
down can be much less time-consuming than placing the person in restraints, which requires
additional resources during the application and during the period following application.

RESTRAINTS AND SECLUSION

When people in crisis become so distressed that they are a danger to themselves or others, it may
be necessary to place them in restraints or to isolate them. Seclusion is the involuntary
confinement of a patient alone in a room or area from which the patient is prevented physically
from leaving. It may be used only for the management of violent or self-destructive behavior. A
restraint is any manual method, physical or mechanical device, material, or equipment that
immobilizes the patient or reduces the ability to move arms, legs, body, or head freely. Such a
restraint may only be used to ensure the immediate physical safety of the patient, a staff member,
or others.

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Seclusion and restraints are safety measures of last resort and not treatment interventions.
Restraints and seclusion do nothing to relieve the patient’s emotional suffering, they do not
change behavior, and they do not help people with serious mental illness to better manage the
thoughts and emotions that trigger behaviors that can injure themselves or others.

WHEN THEY MAY BE USED

Restraints and seclusion may be used only when absolutely necessary or when patients request
seclusion to reduce sensory stimulation. If restraints or seclusion are deemed essential, a
physician may prescribe them but must specify the length of time they may be used, for example,
“for 2 hours within a 12-hour period of time.”

Physical restraints should be applied only by healthcare professionals who are adequately trained
in correct techniques and in protecting patient rights and safety.

Currently there remains a lack of consensus about the use of seclusion and restraints. There are
as yet no uniform national standards over how and when to use restrictive measures. Few states
even require the reporting and investigation of deaths in private or state psychiatric facilities, and
the federal government does not collect data on how many patients are injured or killed by these
techniques (MHA, 2015).

Because history is replete with accounts of the excessive use of restraints and seclusion, current
state laws and recent court decisions affirm that least restrictive measures must be used. (See also
“Ethical and Legal Issues: Restraint/Seclusion” later in this course.) A stated principle of mental
health law, the doctrine of “least restrictive alternative” is an important concept that applies to
the care of patients. This doctrine affirms that caregivers must use the least restrictive means to
achieve a specific end. For example, if four-point restraint of both arms and both legs is enough
to protect disturbed patients from harming themselves or others, they may not be placed in five-
point restraint of the waist, both arms, and both legs.

CHEMICAL RESTRAINTS

A drug is considered a chemical restraint when it is used to manage a patient’s behavior or to

restrict a patient’s freedom of movement and is not a standard treatment or dosage for the
patient’s condition.

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Chemical restraints are medications such as typical and atypical antipsychotics and
benzodiazepines used to restrain agitated or out-of-control persons in mental health emergencies.
Medications have been considered less invasive than physical restraint and seclusion. Currently,
however, no drugs have been approved by the U.S. Food and Drug Administration for use as
chemical restraints, and Black Box warnings for the off-label use of medications have been
issued (Kincaid & Tomasso, 2013).

There remain unresolved issues concerning the use of chemical restraints:

 Are chemical restraints ever appropriate?

 If appropriate, what are the reasonable thresholds for their appropriate use?

Most experts agree that verbal de-escalation is the first choice, considering physical restraints as
the last resort. Concerning chemical restraints, the agreement is that the “ideal” medication
should calm without over-sedating, and oral or inhaled formulations should be preferred over
parenteral routes. Intravenous treatments should be avoided (Garriga et al., 2016; Mattingly,
2016).

A CASE STUDY

Use of Restraints

Jerry, a known mental health patient with bipolar disorder, was admitted at 8:30 p.m. to the
secure unit of the Mental Health Care Center under a 72-hour hold for evaluation. He had been
brought in by the police because of his bizarre behavior in the local mall, grabbing and shoving
people toward an exit and shouting at them to “get out of here, right now! We’re under attack!”
During the night, he was cooperative, but he remained agitated and argumentative.

In the morning, Jerry was taken by a psychiatric technician to the interview room for evaluation
by the psychiatrist, the psychiatric nurse, and the social worker. Initially he was euphoric,
grandiose, and very friendly. As the evaluation proceeded, he suddenly became more agitated.
Attempts were made to help him gain control, but at one point, he jumped out of his chair, ran to
the psychiatrist, and punched him in the face. The psychiatrist fell backward in his chair and hit
his head against the wall. The psych tech picked up the phone and dialed for a “Doctor Green.”

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Using de-escalation techniques, the nurse and the social worker attempted to calm Jerry down,
but he became more belligerent and threatening and took several swings with his fists at the staff.
In less than a minute, the five-member “Doctor Green” team arrived and took Jerry down to the
floor. The team then made the decision to apply restraints based upon the fact that Jerry was
physically combative and a danger to others, unable to be subdued using de-escalation methods,
and further delay in the use of restraints might subject other staff persons to the risk of harm.

The restraint gurney was brought in, and Jerry was placed on his back in four-point leather
restraints. The head of the gurney was raised 30 degrees to avoid aspiration. While restraints
were being applied, the team leader explained to Jerry what they were doing and why. The other
four members of the team each applied a restraint to an extremity and made certain the devices
were secured to the gurney frame and that circulation to the extremities was not compromised.

While Jerry was being restrained, the nurse assessed the patient for immediate first aid needs and
called the medical staff to evaluate his status.

Jerry was taken to an isolation room, and within an hour a member of the medical staff came to
conduct a face-to-face evaluation of the need for restraints. Jerry continued to threaten harm to
staff persons. Following the assessment, an order was written for restraints to be used for the
maximum of four hours per Joint Commission standards.

A psychiatric nurse was assigned to remain in the room with Jerry to continually assess, monitor,
and reevaluate him for the continued need for restraints.

ASSESSMENT

Once the patient’s behaviors are under control and safety is secured, assessment continues in
order to determine the underlying cause of the patient’s presentation. An assessment involves
obtaining medical and psychosocial histories; conducting physical, neurological, and mental
status examination; and assessing for risk of suicide and harm to others.

RULING OUT MEDICAL CONDITIONS

The priority in assessment is to rule out medical conditions as the cause of the patient’s
psychiatric symptoms. All patients should have a detailed history, a complete physical

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examination, including neurological, and mental status examinations before medical stability can
be concluded.

Criteria that can be used to aid in identifying a medical cause of psychiatric symptoms include:

Organic Clues

1. Age less than 12 or older than 40

2. Sudden onset (within hours to days)
3. Fluctuating course
4. Disorientation
5. Decreased consciousness
6. Visual hallucinations
7. No psychiatric history
8. Emotional lability
9. Abnormal vital signs
10. Abnormal physical exam findings
11. History of substance abuse

Psychogenic Clues

1. Age 13 to 40 years
2. Gradual onset (weeks to months)
3. Continuous course
4. Scattered thoughts
5. Awake and alert
6. Auditory hallucinations
7. Psychiatric history
8. Flat affect
9. Normal physical exam findings (Emembolu & Zun, 2010)

A rapid blood glucose determination and pulse oximetry should be obtained on all acute
psychiatric patients. A consensus exists among emergency physicians, however, that other

21
laboratory and other diagnostic testing needs to be individually determined, based upon history
and clinical presentation rather than blanket profiles.

Additional studies that may be useful in selected patients include serum electrolytes, blood and
urine toxicology screening, serum ethanol, thyroid screening, and cranial imaging. An ECG may
be useful in assessing an older adult (ACEP, 2014; Moore & Pfaff, 2017).

MENTAL STATUS EXAMINATION

After the physical and neurological examination is completed, a mental status examination
(MSE) should be done to evaluate critical areas of cognition and emotion. A systematic approach
to assessing mental status is a key element in the identification of alterations in mental status and
for directing diagnostic testing and management.

Although there are standardized tools to accomplish this, the exam remains primarily subjective
beginning when the patient enters the healthcare setting. In an emergency, clinicians may need to
modify the examination. Legally, obtaining consent is a must for anything other than a routine
physical examination. If a mental status examination is conducted against the patient’s will, it is
considered assault with battery. Therefore, it is important to secure the patient’s permission or to
document that a mental status examination is being done without the patient’s approval in an
emergency situation (Brannon, 2016).

CLINICAL INTERVIEW

An emergency psychiatric evaluation is often requested when a patient presents with an

immediate harm to self or others, when such a threat is thought to exist, or when there is a need
to identify a psychiatric diagnosis. A clinical interview is conducted face-to-face to gather
pertinent data and explore the presenting problem. The interview method is modified to match
the circumstances, age, and cognitive ability of the person in crisis. Data collection is enhanced
by information gathered from family members, other healthcare providers, and authorities such
as police officers. Assessment includes the person’s perception of the event, situational supports,
and coping skills. (See also “Crisis Intervention Model: Stage 1” earlier in this course.)

22
Having a psychiatrist available to see patients either in person or via telemedicine has been
shown to decrease the need for inpatient admission. Telemedicine can be an effective tool for
patient evaluation, allowing for access to care in an emergency setting (Wiler et al., 2014).

The face-to-face clinical interview should take place in a quiet, safe environment, and the
maintenance of such an environment should be emphasized to the patient at the beginning.
Patients may require medication prior to being interviewed, and if a patient is potentially
assaultive, it is best that the interview be conducted with multiple staff members present.

If the patient is in restraints, the initial step should be to let the patient know what is required in
order to have the restraints removed. If the patient is not restrained, the clinician should not block
exit from the interview area or be situated in such a way that there is no escape.

The clinical interview begins with identification of the chief complaint followed by the history of
present illness. If the patient is capable, a longitudinal history of the course of the illness can be
explored; but if the patient is too impaired to completely participate, the emphasis should be on
the current episode. The history of present illness should include information about how the
patient was functioning prior to the episode, the current symptoms, whether there is a past
history of prior episodes, and what the precipitating factors were. It is also important to examine
recent or chronic stressors and their severity and to assist the patient to connect the stressors to
the symptoms of the current crisis.

The patient should be asked about any psychiatric history, past treatment, and illness episodes. It
is important to remember that a denial of a history of mental illness in the past should not be
accepted without further inquiry, as stigma may play a significant role in unwillingness to
disclose such a history.

A review of systems should be done to attempt to discover other issues not brought up during the
history of present illness (Scher, 2016; Moore & Pfaff, 2017).

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 CRISIS INTERVENTION PROCESS

In order to develop basic crisis intervention skills it is necessary to have a model on which one
can work from, allowing you to understand the situations that bring a person into crisis (chiefly
things that overwhelm a person’s coping strategies, where they find themselves unable to take
further positive action), and the tasks that must be completed to help them successfully navigate
such a crisis.These steps form the foundation of intervening with an individual to help give them
a sense of control and help to restore basic coping skills.

Step 1. Defining the Problem

The first step in crisis intervention process is to determine exactly what the problem is. This part
of the process helps establish a connection between yourself and the client. The active
listening process is important here: open-ended questions and the core factors of empathy,
genuineness and positive regard.

Step 2. Ensuring Client Safety

The next step is to ensure the safety of the client. This involves suicide risk assessment, as well
as checking homicide risk. Removing access to lethal means of suicide as well as other items that
can be used to hurt yourself and the client are important. For instance, in an average office,
scissors, paper cutters, staplers and three-hole punches can all be used to injure self or others.

Step 3. Providing Support

After the client is physically safe and the problem has been adequately defined, the next step is
for the crisis worker to accept the client as a person of value and communicate that they care
about them. This can involve simply talking to the client about what’s going on in their life,
taking care of basic needs (e.g. food and shelter.)

Once the client has their basic needs met, the next part of providing support is ensuring the client
has enough information to understand their available options for dealing with their situation.

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Step 4. Examining Alternatives
In step 4, Examining Alternatives, the client is encouraged to explore potential solutions to what
they’re dealing with. A client whose coping skills are suspended will have difficulty coming up
with options and this is where the crisis worker comes in.

James identifies three categories of potential alternatives:

A. Situational Supports – individuals around the client who “might care about what happens
to the client”
B. Coping mechanisms – “Actions, behaviours or environmental resources” the client can
draw on to help get through their situation. Assessing coping skills is a key part of
telephone crisis intervention, which should explore what they did in the past, present, and
then future
C. Positive and constructive thinking patterns – New ways of thinking about the client’s
situation that can help them reframe
Step 5. Making Plans
Now that the client trusts the crisis worker, they have provided immediate safety and met basic
needs, explored alternatives, it’s time to make a plan. The goal of this step is to focus on concrete
steps that can help restore control in the client’s life, and identify other referral resources that can
help provide the client additional support.

Making sure the plans are realistic and not overwhelming is a key part of step 5. Clients must
feel empowered by the plan in order for them to proceed with it, therefore working
collaboratively is extremely important. Many clients have been disempowered or oppressed
before seeking (or being forced into) treatment, and continuing this pattern will lead to poor
outcomes.

Step 6. Obtaining Commitment

The final step of the process, is obtaining commitment. If you’ve worked together with your
client, obtaining commitment should be easy. You may need to write down the plan for the
particularly overwhelmed client to keep track of it, and follow up with them to ensure that they
have followed through with the plan

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 ROBERT’S’ SEVEN STAGE CRISIS INTERVENTION MODEL

In conceptualizing the process of crisis intervention, Roberts (1990, 1991, 1995, 2000,

2005) has identified seven stages through which clients typically pass on the road to crisis

stabilization, resolution, and mastery. These stages, listed below, are essential and overlapping in

the process of crisis intervention:

e. Plan and conduct a thorough biopsychosocial and lethality/imminent danger assessment

f. Make psychological contact and rapidly establish the relationship

g. Identify the major problems, including crisis precipitants

h. Encourage an exploration of feelings and emotions

i. Generate and explore alternatives

j. Restore functioning through implementation of an action plan

k. Follow-up

Stage I: Psychosocial and Lethality Assessment

The crisis worker must conduct a swift but thorough biopsychosocial assessment. At a

minimum, this assessment should cover the client’s environmental supports and stressor, medical

needs and medications, current use of drugs and alcohol, and internal and external coping

methods and resources (Eaton & Ertl, 2000). One useful (and rapid) method for assessing the

emotional, cognitive, and behavioral aspects of a crisis reaction is the Triage Assessment Model

(Myer, 2001; Myer, Williams, Ottens, & Schmidt, 1992).

Assessing lethality, first and foremost, involves ascertaining whether the client has

actually initiated a suicide attempt, such as ingesting a poison or overdose of medication. If no

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suicide attempt is in progress, the crisis worker should inquire about the client’s potential for

self-harm. This assessment requires

 Asking about suicidal thoughts and feelings (e.g., “When you say you can’t take it

anymore, is that an indication you are thinking of hurting yourself?”)

 Estimating the strength of the client’s psychological intent to inflict deadly harm (e.g., a

hotline caller who suffers from a fatal disease or painful condition may have strong

intent)

 Gauging the lethality of suicide plan (e.g., does the person in crisis have a plan? how

feasible is the plan? does the person in crisis have a method in mind to carry out the plan?

how lethal is the method?)

 Inquiring about suicide history

 Taking into consideration certain risk factors (e.g., is the client socially isolated or

depressed, experiencing a significant loss such as divorce or lay-off?)

With regard to imminent danger, the crisis worker must establish, for example, if the

caller on the hotline is now a target of domestic violence, a violent stalker, or sexual abuse.

Rather than grilling the client for assessment information, the sensitive clinician or

counselor uses an artful interviewing style that allows this information to emerge as the client’s

story unfolds. A good assessment is likely to have occurred if the clinician has a solid

understanding of the client’s situation and the client, in this process, feels as though he or she has

been heard and understood. Thus, it is quite understandable how in the Roberts Model Stage I

and Stage II, Rapidly Establish Rapport, are very much intertwined.

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Stage II: Make Psychological Contact and Rapidly Establish Rapport

Rapport is facilitated by the presence of counselor-offered conditions such as

genuineness, respect, and acceptance of the client (Roberts, 2005). This is also the stage in which

the traits, behaviors, or fundamental character strengths of the crisis worker come to fore in order

to instill trust and confidence in the client. Although a host of such strengths have been

identified, some of the most prominent include poise, creativity, flexibility, resiliency, and

optimism (see James & Gilliland, 2005, pp. 14-16).

Stage III: Identify the Major Problems or Crisis Precipitants

Crisis intervention focuses on the client’s current problems, which are often the ones that

precipitated the crisis. As Ewing (1978) pointed out, the crisis worker is interested in elucidating

just what in the client’s life has led her or him to require help at the present time. Thus, the

question asked from a variety of angles is, “Why now?”

Roberts (2005) suggested not only inquiring about the precipitating event (the proverbial

“last straw”) but also prioritizing problems in terms of which to work on first, a concept referred

to as “looking for leverage” (Egan, 2002). In the course of understanding how the event escalated

into a crisis, the clinician gains an evolving conceptualization of the client’s modal coping style

—one that will likely require modification if the present crisis is to be resolved and future crises

prevented. For example, Ottens & Pinson (2005) in their work with caregivers in crisis has

identified a repetitive coping style—argue with care recipient-acquiesce to care recipient’s

demands-blame self when giving in fails—that can eventually escalate into a crisis.

Stage IV: Deal with Feelings and Emotions

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 There are two aspects to Stage IV. The crisis worker strives to allow the client to express

feelings, to cathart, and to explain her or his story about the current crisis situation. To do this,

the crisis worker relies on the familiar “active listening” skills like paraphrasing, reflecting

feelings, and probing (Egan, 2002). Very cautiously, the crisis worker must eventually work

challenging responses into the counseling dialogue. Challenging responses can include giving

information, reframing, interpretations, and playing “devil’s advocate.” Challenging responses, if

appropriately applied, help to loosen clients’ maladaptive beliefs and to consider other behavioral

options. For example, a young woman who found boyfriend and roommate locked in a cheating

embrace, the counselor at Stage IV allows the woman to express her feelings of hurt and jealousy

and to tell her story of trust betrayed. The counselor, at a judicious moment, will wonder out loud

whether taking an overdose of acetomeniphen will be the most effective way of getting her point

across.

Stage V: Generate and Explore Alternatives

This stage can often be the most difficult to accomplish in crisis intervention. Clients in

crisis, by definition, lack the equanimity to study the big picture and tend to doggedly cling to

familiar ways of coping even when they are backfiring. However, if Stage IV has been achieved,

the client in crisis has probably worked through enough feelings to reestablish some emotional

balance. Now, clinician and client can begin to put on the table options, like a no-suicide contract

or hospitalization, for ensuring the client’s safety; or discuss alternatives for finding temporary

housing; or consider the pros and cons of various programs for treating chemical dependency. It

is important to keep in mind that these alternatives are better when they are generated

collaboratively and when the alternatives selected are “owned” by the client.

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 The clinician certainly can inquire about what the client has found that works in similar

situations. For example, it frequently happens that relatively recent immigrants or bicultural

clients will experience crises that occur as a result of a cultural clash or mismatch, as when

values or customs of the traditional culture are ignored or violated in the United States. It may

help to consider how the client has coped with or negotiated other cultural mismatches. If this

crisis precipitant is a unique experience, then clinician and client can brainstorm alternatives—

sometimes the more outlandish, the better—that can be applied to the current event. Solution-

focused therapy techniques, such as “Amplifying Solution Talk” (DeJong & Berg, 1998) can be

integrated into Stage IV.

Stage VI: Implement an Action Plan

Here is where strategies become integrated into an empowering treatment plan or

coordinated intervention. Jobes and Berman (1996), who described crisis intervention with high-

risk, suicidal youth, noted the shift that occurs at Stage VI from crisis to resolution. For these

suicidal youth, an action plan can involve several elements:

 Removing the means—involving parents or significant others in the removal of all lethal

means and safeguarding the environment

 Negotiating safety—time-limited agreements during which the client will agree to

maintain his or her safety

 Future linkage—scheduling phone calls, subsequent clinical contacts, events to look

forward to

 Decreasing anxiety and sleep loss—if acutely anxious, medication may be indicated but

carefully monitored

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  Decreasing isolation—friends, family, neighbors need to be mobilized to keep ongoing

contact with the youth in crisis

 hospitalization—a necessary intervention if risk remains unabated

Obviously, the concrete action plans taken at this stage (e.g., entering a 12-step treatment

program, joining a support group, seeking temporary residence in a women’s shelter) are

critical for restoring the client’s equilibrium. However, there is another dimension that is

essential to Stage VI, as Roberts (2005) indicated, and that is the cognitive dimension. Thus,

recovering from a divorce or death of a child or drug overdose requires making some

meaning out of the crisis event: why did it happen? What does it mean? What are alternative

constructions that could have been placed on the event? Who was involved? How did actual

events conflict with one’s expectations? What responses (cognitive or behavioral) to the

crisis actually made things worse? Working through the meaning of the event is important for

gaining mastery over the situation and for being able to cope with similar situations in the

future.

Stage VII: Follow-up

Crisis workers should plan for a follow-up contact with the client after the initial

intervention to ensure that the crisis is on its way to being resolved and to evaluate the postcrisis

status of the client. This postcrisis evaluation of the client can include:

 Physical condition of the client (e.g., sleeping, nutrition, hygiene)

 Cognitive mastery of the precipitating event (does the client have a better understanding

of what happened and why it happened?)

 An assessment of overall functioning including, social, spiritual, employment, academic

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  Satisfaction and progress with on-going treatment (e.g., financial counseling)

 Any current stressors and how those are being handled

 Need for possible referrals (e.g., legal, housing, medical)

Follow-up can also include the scheduling of a “booster” session in about a month after the

crisis intervention has been terminated. Treatment gains and potential problems can be discussed

at the booster session. For those counselors working with grieving clients, it is recommended that

a follow-up session be scheduled around the anniversary date of the deceased’s death (Worden,

2002).

ETHICAL PRINCIPLES AND MENTAL CRISES

Ethical principles are fundamental concepts by which people make decisions. Healthcare
professionals follow ethical standards of care at all times, whether or not a patient is in crisis.
These standards are based on ethics, the branch of philosophy concerned with the rightness or
wrongness of human behavior and the goodness or badness of its effects. However, in emergency
circumstances where there is a need to intervene rapidly, caregivers may sometimes be
challenged to remember the importance of such principles.

Ethical principles serve as general guides for behavior. There are four commonly accepted
principles of healthcare ethics:

l. Respect for autonomy

 Nonmaleficence
 Beneficence
 Justice

Respect for autonomy: means respecting the right of self-determination, independence, and
freedom. This principle implies that the patient has the capacity to act intentionally, with
understanding, and without controlling influences that would negatively impact a free and
voluntary act. This is the principle underlying the practice of “informed consent,” wherein the

32
provider gives factual, scientific, and relevant information about treatment, including benefits
and risks. The issue of veracity or truth-telling is closely related to that of informed consent, as it
involves weighing paternalistic concerns against the autonomy interests of the patient (BRL at
GU, 2016; McCormick, 2013).

When applied to mental health crises, autonomy means caregivers:

 Inform patients about treatment options and risks, making sure theyunderstand
 Respect and accept decisions made by patients about their personal care
 Implement and evaluate interventions chosen by patients
 Hold in confidence all personal information, divulging it only when patients

or their legal guardians give permission

Nonmaleficence: means to do no harm, or to inflict the least harm possible, to reach a beneficial
outcome. The pertinent ethical issue is whether the benefits of treatment or intervention outweigh
the risks or burdens. The potential benefits of any treatment or intervention must outweigh the
risks in order for the action to be ethical.

Beneficence: means that healthcare providers have a duty to be of benefit to the patient. The
principle implies that a patient can enter into a relationship with a person that society has
licensed or certified as competent to provide healthcare, and that actions taken by such a person
will help prevent or remove harm or simply improve that patient’s situation.

When applied to mental health crises, beneficence means caregivers:

 Relate to patients professionally and objectively

 In consultation with other clinicians, follow treatment plans
 Choose the option that will do good and avoid harm
 Recognize that under certain conditions beneficence overrides autonomy and that
compulsory treatment may be justified

Justice: implies fairness and equality, requiring impartial treatment of patients. Like other ethical
principles, justice is based on respect for human life and dignity (McCormick, 2013). The
historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of

33
objective evidence and judicial precepts. Justice means that scarce resources will be distributed
equally, using the same criteria for everyone.

Laws and Mental Health Crises

Laws flow from ethical principles and consist of rules about specific situations. These rules are
enforced by an authority with the power to see that they are obeyed. In recent years, the number
and scope of state, federal, and case laws that affect the treatment of people with psychiatric
disorders has increased dramatically. Of special interest to those who care for people in crisis are
laws concerning civil rights, confidentiality, patient rights, treatment decisions, restraints,
seclusion, and hospital confinement.

CIVIL RIGHTS

Under federal and state laws, people with mental illness are guaranteed the same civil rights as
every other citizen in the land. These laws guarantee the rights of all people to humane care, to
interact socially, to press charges against others, to vote, to speak, to enter into contractual
relationships, to make purchases, to obtain a license to drive an automobile, to follow religious
practices, to participate in legal activities, and to travel within the United States.

Some laws that address these rights include:

 Americans with Disabilities Act

 Fair Housing Amendments Act
 Civil Rights of Institutionalized Persons Act
 Individuals with Disabilities Education Act

(Goldberg, 2016b)

CONFIDENTIALITY

In 1996, to protect the privacy of individuals and the confidentiality of patient records at the
dawn of the age of electronic data collection, the U.S. Congress passed the Health Insurance
Portability and Accountability Act (HIPAA). Phased in between 2000 and 2003, HIPAA
provides that without the prior consent of patients or their legal guardian, medical records may

34
not be read or copied. The act affirms the right to privacy and supports the concept of respect for
all human beings.

PATIENT RIGHTS

“Patient rights” refers to a general statement adopted by most healthcare professionals that
covers matters including access to care, patient dignity, confidentiality, and consent to treatment.
These basic rights include:

12. The right to open and honest communication between the patient and the healthcare
provider
10. The right to informed consent based on the moral and legal premise of patient autonomy
 The right to confidentiality, subject to certain exceptions because of legal, ethical, and
social considerations (i.e., risk of harm to self or others)
 The right to healthcare (although the right to healthcare in the United States is open to
debate, the Consolidated Omnibus Budget Reconciliation Act [COBRA] and the
Emergency Medical Treatment and Active Labor Act [EMTALA] mandate an evaluation
for patients seeking attention at emergency facilities regardless of ability to pay)
 The right to not be abandoned by a healthcare provider unless the patient is referred,
transferred, or no longer requires treatment and is discharged
 The right to refuse care (exceptions occur for those without the ability to make a
competent decision) (Davis, 2016)

TREATMENT DECISIONS

The Hospitalization of the Mentally Ill Act of 1964 requires that all patients in public hospitals
have a right to treatment. Prior to that time, patients could be hospitalized for indefinite periods
of time without treatment. Since then, the courts have ruled that patients must be cared for in a
humane environment by sufficient numbers of qualified clinicians according to individualized
care plans.In other rulings, both federal and state courts have ruled that patients have the right to
refuse electroconvulsive therapy and antipsychotic medications.

35
Furthermore, according to the Federal Patient Self-Determination Act of 1990, patients have the
right to prepare an “advance care directive” that will be respected in case they become
incapacitated (NRCPAD, 2015).

Restraint/Seclusion

To prevent injury in mental health crises, clinicians may need to restrain patients, administer
tranquilizing drugs, or place patients in seclusion against their will. Similarly, when a patient is a
danger to self or others, as with the patient who hears voices telling him to hurt himself, it may
be necessary to call the authorities for emergency involuntary commitment. The individual is
then restrained and taken to a locked facility for evaluation and treatment. These situations raise
both legal and ethical issues, including the ethical dilemma created by the conflict of the ethical
principles of autonomy and beneficence.

HOSPITAL CONFINEMENT

Admission to the hospital related to a mental health crisis emergency may be either voluntary or
involuntary.

 Voluntary means the patient is in control and decides when to enter the facility and when
to leave.
 Involuntary means the patient does not have to agree to admission.

Discharge from the hospital depends on the status of patients at the time they were admitted. In
general, those who entered voluntarily have the right to be released voluntarily unless their
condition changes significantly during their hospitalization. Some states provide a conditional
release of people who were admitted voluntarily. Such a provision allows physicians or
administrators to arrange for ongoing treatment on an outpatient basis.

Emergency involuntary commitment of people in crisis, also called civil commitment , is

controlled by state statutes specifying the conditions under which people can be held against
their will. In general, involuntary admission is permitted when people are a danger to
themselves, a danger to others, or gravely disabled (unable to provide for their basic human
needs such as food, clothing, shelter, health, or safety).

36
Many states give police officers, physicians, and certain mental health professionals authority to
judge the mental status of individuals and to indicate the length of time they are to be held
against their will. Often, that time is 72 hours, during which the person is evaluated and a plan of
care is devised.

Civil commitment for observation , also called temporary involuntary hospitalization , is for a
longer period of time than emergency hospitalization. Its primary purpose is observation,
diagnosis, and treatment of people who have a mental illness or pose a danger to themselves or
others. The length of time is specified by statute and varies from state to state. Application for
this type of commitment can be made by a guardian, family member, physician, or other public
health officer and may require a certificate affirming mental illness.

Long-term commitment for involuntary hospitalization is intended to give patients extended

care and treatment. As with patients who undergo temporary involuntary hospitalization for
observation, extended involuntary hospitalization can occur only with judicial or administrative
action and medical certification.This type of involuntary hospitalization may be for 60 to 180
days or, under some circumstances, for an indeterminate period of time.

Involuntary outpatient commitment is a legal category of care that was initiated in 1990
following the doctrine of the least restrictive alternative. Involuntary outpatient treatment is
court-ordered, community-based treatment for people with untreated severe mental illness. These
individuals are often too ill to know they need medical care and have a history of medication and
treatment noncompliance. The goal is to provide treatment before they require inpatient
treatment by reducing homelessness, violence, and noncompliance. Opponents to this form of
treatment feel it removes a patient’s civil right to choose where and how to receive care.

Although every state and the District of Columbia have emergency involuntary commitment
laws, state law varies on the length of such holds, who can initiate an emergency hold, extent of
judicial oversight, and the rights of patients during the commitment. The main criterion that
justifies an involuntary commitment is mental illness that results in danger to self or others, but
many states have added further specifications. Only 22 states require some form of judicial
review of the emergency commitment process, and only nine require a judge to certify the

37
commitment before a person is hospitalized. Five states do not guarantee assessment by a
qualified mental health processional during an emergency commitment (Hedman et al., 2016).

Example

Victoria, a 48-year-old woman with a long-standing manic disorder, built a fire on her living
room floor, and when her husband tried to extinguish the fire, she attempted to stab him with a
knife. She was taken by police to the emergency department and admitted involuntarily for
treatment, where she accepted medications to help her sleep but declined to take any mood-
stabilizing drugs. She said, “They make me feel like I’m moving in slow motion, going through
Jell-O. I can’t stand them.” The healthcare team recognized the dilemma among the three ethical
principles of beneficence (providing treatment), autonomy (right of self- determination), and
justice (fairness and equality).

In Victoria’s case, a crisis situation, it was readily accepted that treatment with medications was
clinically indicated and likely to be of benefit (beneficence). They also recognized that Victoria
has significant mental illness and her ability to make informed decisions was seriously impaired
(autonomy). The decision to involuntarily commit her was based on dangerousness evidenced by
the attempt to stab her husband. Equal treatment would require Victoria to be charged with a
criminal act (justice). Instead, Victoria was court-ordered to be detained and started on lithium
600mg per day in three divided doses, recognizing that the potential benefits of the treatment
outweighed the risks (nonmaleficence).

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 REFERENCES

Judith Swan and Persis Mary Hamilton; Wild Iris Medical Education, Inc. 2017

Scher L. (2016). Psychiatric interview. Medscape. Retrieved from

http://emedicine.medscape.com

Smith S, Barston S, & Seagal J. (2014). Teen depression: a guide for parents. Retrieved from
http://www.helpguide.org

Suthar S. (2015). Crisis intervention in psychiatry. Retrieved from https://www.slideshare.net

Thompson J. (2013). Active listening techniques of hostage & crisis negotiators. Retrieved from
https://www.psychologytoday.com

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