SPECIAL REPORT: PSYCHIATRIC EMERGENCIES
“It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.”
—Arthur Conan Doyle, “A Scandal in Bohemia”1
As the fictional detective Sherlock Holmes notes, the pursuit of truth and facts is not one to be taken lightly. In the field of medicine, the topic of diagnostics is perpetually under pressure to evolve and surpass past performances.
In psychiatry, the idea of diagnostics, assessment, and prognosis has a long history that many have categorized, debated, and (to this day) reviewed.2 However, unlike our peers in other medical specialties, we do not have the luxury of the full use of computed tomography or tissue biopsy. Instead, our best analogue to laboratory studies and invasive procedures is the psychiatric interview. Honing one’s skills in this regard is akin to optimizing the act of auscultation or laparoscopic investigation.
IN THIS SPECIAL REPORT
The Promise and Potential of Emergency Psychiatry
Scott Zeller, MD, Special Report Chair
The Field as a Master Class in Interviewing
Tony Thrasher, DO, DFAPA
CAHOOTS: A Model for Prehospital Mental Health Crisis Intervention
Ben Adam Climer and Brenton Gicker
10 Most Common Presentations in Emergency Psychiatry
Scott Zeller, MD, Special Report Chair
Infographic: Never a Dull Moment in Emergency Psychiatry
Scott Zeller, MD
The Psychiatric Interview
Tony Thrasher, DO, DFAPA
Emergency Psychiatry: The Intertwining of Physical and Mental Health
Scott Zeller, MD
Like other methods of diagnosis, the psychiatric interview can not only uncover an etiology but also serve as a form of treatment. Nowhere is this exemplified so regularly and explicitly as in psychiatric emergency services and crisis intervention. Let us examine how an assessment as an emergency psychiatrist truly can be perceived as a master class in the psychiatric interview.
Several conflicting factors must first be noted and resolved: ethical tensions, autonomy vs beneficence; legal components, civil rights vs police power; and clinical decisions needing completion and ownership, medical decision-making vs public interest and scope of patient-centered processes. In examining all this, it is obvious how emergency psychiatry provides a master class in the medical skill of interviewing.
“Life is infinitely stranger than anything which the mind of man could invent. We would not dare to conceive the things which are really mere commonplaces of existence.” —Arthur Conan Doyle, “The Adventure of the Bruce-Partington Plans”3
In emergency psychiatry, one must conduct an interview while managing efficiency, acuity, and extensive medical complications. As such, it is an area where maintaining a broad medical proficiency is paramount, and this it goes far beyond the crucial understanding of medical stabilization processes (ie, medical clearance).4 Once an individual has been cleared for further psychiatric care, many items pertaining to the patient’s chief complaint and ongoing medical comorbidities are a focus during the emergency interview.5 How a physician uncovers those items plays a primary role in the successful of the psychiatric intervention.
The emergency psychiatrist must not only maintain a broad medical understanding, but also be skilled and comfortable with a wide degree of risk tolerance and mitigation strategies. The most familiar risks often pertain to suicide and homicide; however, there are a plethora of risk items that must be addressed in every crisis interview. A nonexhaustive list is in the Table.6
The third leg of the tripartite successful psychiatric interview includes multitasking and time management (Figure). Unlike in other interview milieus, these assessments cannot usually be deferred, delayed, or done in a preliminary fashion.
These interviews are often performed in contexts that are complex in terms of acuity, physical plant, and medicolegal stakes. The emergency psychiatrist’s decisions do not occur in a vacuum nor do they go unwitnessed, unnoticed, or without scrutiny. There are many shareholders, and, as such, the psychiatric interview is of great complexity when noting the relationships considered. Rather than viewing this through a patient-physician scope, the emergency psychiatry interview requires broadening that aperture to a patient-physician-family-advocate-guardian-law enforcement-case worker-community individual-probate court lens.
Now, noting that the emergency interview requires sophistication in medical care, risk management, and timeliness, it is also worthwhile to remark how this master class in interviewing attends not only to diagnostics, but also to therapeutics and treatment.
“The world is full of obvious things which nobody by any chance ever observes.” —Arthur Conan Doyle, “The Hound of the Baskervilles”7
A skilled psychiatric interview can function as both treatment and assessment,8 especially in an emergency psychiatric situation. The clinician must establish immediateand effective rapport, master service recovery, and appreciate the finer points of psychodynamics in the interview process.
One of the greatest challenges of a complex emergency psychiatric interview is that it may be the psychiatrist’s only chance to ever interact with the patient. As such, the stakes are higher, the room for error diminished, and the overall emotional valence to patient and loved ones quite accentuated. The most gifted emergency department interviewers are able to establish rapport in a sincere, direct manner that can reach those in crisis on their darkest days. Not only will this rapport help in lessening a patient’s agitation, but the intervention leads to an enhanced accuracy of whatever information is obtained, as well as to patient satisfaction.9 A successful emergency interview, consequently, will have tenets of trauma-informed care, patient-centered processing, and autonomous medical decision as core competencies.
Occasionally, when you are dealing with patients during their most difficult times, they will be upset regardless of your intentions. Consequently, the emergency psychiatric interviewer must be aware of and accept advanced service recovery techniques.10 A patient’s recovery may actually be due to something that occurred in your setting or, more commonly, to events that preceded their arrival. This would include patients who were conveyed to your setting involuntarily and/or those not engaging in the interview as the primary requestor of services.
In the overall field of crisis services, success also highlights the importance of redressing grievances or concerns in the moment. Redressing grievances will assist not only with patient satisfaction, but also with patient loyalty and trust over time.11 Marketing data indicate that users of a service are often more impressed when a provider deals with an issue successfully,12 as opposed to when an issue never presents itself.
Although the acuity and speed of the psychiatric emergency settings tend to focus on the biological components of medical research, there are many important aspects to the psychiatric interview rooted in psychodynamic theory. Aside from the rapport, the physician has to fully contextualize the transference and countertransference to successfully engage the patient in a way that benefits both patient and examiner. Additionally, the defense mechanisms noted in a crisis are of priceless significance when trying to navigate items that are lacking in possible maturity but also varying degrees of neuroticism.13 Once the clinician has moved into the deeper stages of the interview, using techniques pertaining to neutrality, observation, clarification, and confrontation is also beneficial.
“My mind rebels at stagnation.”
—Arthur Conan Doyle, “The Sign of the Four”14
As one can see, the master class in emergency psychiatric interviewing has components of core skills—medical knowledge, risk assessment, efficient multitasking—as well as techniques that lead to beneficial outcomes for all involved—service recovery, dynamics, rapport establishment.
The unique challenges to interviewing in these contexts are the varied stakeholders, laws, and tenets that one must juggle, maintain, and provide quality service toward.15 To be successful in this arena, one must have proficient communication skills regarding, for example, handoffs with emergency medicine, pediatrics, hospitalists, internists, and/or surgical specialists, as well as when dealing with allied health care colleagues and the lay population. To put a finer point on this, there could be individual patient cases in which the emergency psychiatrist must not only conduct an efficient assessment but also specify the findings to multiple individuals with differing communication needs.16
Imagine you are working with a young patient showing signs of psychosis for the past 6 weeks. Your initial assessment appears to rule out medical- or substance-induced etiologies, and the overall clinical picture appears to support the onset of a new primary psychotic disorder. Next steps may include communicating with the patient and their family regarding what this means, while balancing civil rights and the topic of voluntary vs involuntary care. Furthermore, you then need to process engagement, consent, and the desire for long-term treatment.17 Finally, you need to consider differing styles and options while reaching out to inpatient units for possible admissions. You may be chatting with a variety of personnel when trying to enroll the patient in a first episode psychosis intense outpatient program.
At the rather loud nursing station, you receive calls from the law enforcement group that brought in the individual with concerns about criminal charges and/or restraining orders from neighbors involved in past crisis episodes.18 As you think you are finally settling down to compose your note in the electronic heath record, you receive a final request from the training medical student about a disability specialist holding on the phone for you to discuss how the patient’s benefits are being affected by the next dispositional decisions.
Although this is a scenario documented for dramatic effect, it is not far removed from a typical case in a psychiatric emergency setting. Hence, these interviewers must maintain professionalism and a calm demeanor while balancing multiple acute needs from various individuals. These sources may all require a number of tactics to best meet all the needs, and the skilled emergency psychiatrist must find a way to manage demands in the most challenging scenarios imaginable.
If you want to be a skilled interviewer like Holmes, you need not engage in social cocaine usage, perform late-night violin recitals, or anger police officers in Victorian England. Instead, simply turn to the field of emergency psychiatry, which is filled with passionate individuals who are highly skilled in the area. In doing so, you will find long-standing seekers of advanced acumen, performance, and abilities.
“Education never ends, Watson. It is a series of lessons with the greatest for the last.”—Arthur Conan Doyle, “The Adventure of the Red Circle”19
Dr Thrasher is the president of the American Association for Emergency Psychiatry (AAEP) and the medical director of crisis services in Milwaukee county, Wisconsin.
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