psychiatric emergencies: overview of clinical principles...

Clinical Social Work JournalVol. 17, No. 3, Fall 1989

PSYCHIATRIC EMERGENCIES: OVERVIEWOF CLINICAL PRINCIPLES AND

CLINICAL PRACTICE

Christina E. Newhill

ABSTRACT: Psychiatric emergency work as a unique form of crisis inter-vention is examined. Basic practice principles are identified including commonintervention pitfalls that can occur especially with the novice helper. Five of themost prevalent categories of psychiatric emergencies are discussed with illustra-tions provided via case examples culled from the author's clinical practice.

The most urgent types of psychiatric crises are psychiatric emer-gencies. They involve sudden severe changes in emotions or behaviorwhich, if unchecked, pose serious threats of physical, emotional or socialharm. Examples include suicide attempts, homicide attempts or psy-chotic decompensation. The common criteria for civil commitment—danger to self, danger to others and grave disability—reflect the verydefinition of a psychiatric emergency. With prompt appropriate inter-vention, however, a psychiatric emergency does not have to result in in-voluntary hospitalization. It is beyond the scope of this article to providean overview of the complete range of possible psychiatric emergenciesand intervention techniques. Therefore, basic intervention principleswill be discussed with five of the most common types of psychiatricemergencies highlighted and illustrated by case examples drawn fromthe author's clinical practice.

REVIEW OF THE LITERATURE

The hasic interviention model for psychiatric emergency work is cri-sis intervention. After almost five decades of development, however, cri-

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sis intervention theory and practice is still evolving. A comprehensivereview of the literature clearly demonstrates a recurrent hesitancywithin the field to define and commit to a specific theoretical frameworkeven though crisis intervention practice has generally gained wide-spread acceptance among mental health professionals as a valid practiceapproach (Slaikeu, 1984; Baldwin, 1978, 1979; Taplin, 1971; Easthamet al., 1970).

The origin of modern crisis intervention methodology can be tracedto the work of Erich Lindemann (1944) and his colleagues following theCoconut Grove night club fire in Boston on November 28, 1942 in which493 people perished. His clinical report on the psychological aftermathof the tragedy and the intervention strategies utilized became a founda-tion for the development of crisis theory as a conceptual framework forpreventive psychiatric interventions.

Drawing from Lindemann's work, Gerald Caplan (1964) developedthe concept of preventive psychiatry which has as its primary goal lifecrisis intervention of a preventive nature to promote positive growthand minimize psychological impairment. This concept is commensuratewith the notion of crisis as a turning point—a time of both danger andopportunity. Danger arises when the crisis resolution results in reducedability to deal with subsequent life stresses; opportunity manifestswhen the crisis period results in increased health and maturity.

Current crisis intervention theory still draws heavily from the orig-inal theoretical framework developed by Caplan over twenty years ago(Aguilera & Messick, 1982; Baldwin, 1979; Slaikeu, 1984). Some subse-quent supportive research has been done and some of the literature hasexpanded on Caplan's thinking but the central premises have remainedwith little change.

The psychiatric emergency literature has been dominated by thework of psychiatrists, nurses, psychologists and paraprofessionals (e.g.Slaby, Lieb & Tancredi, 1986; Walker, 1983; Bassuk & Birk, 1984;Cumming, 1983). Although some clinical social work literature hasemerged in this field (see for example, Grumet & Trachtman, 1976;Groner, 1978; Fein & Knaut, 1986) the output has been scanty and hasrarely addressed clinical social workers in the role of primary psychiat-ric emergency intervener as opposed to support or adjunctive roles. Thisarticle, however, is addressed to the clinicial social worker who findshim/herself in the position of directly resolving a psychiatric emergency.Psychiatric emergencies may occur in all practice contexts and as clin-icial social workers have enlarged their range of expertise, so have theyenlarged the probability of encountering an emergency situation.

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CHRISTINA E. NEWHILL

BASIC PRINCIPLES

The basic intervention model for psychiatric emergency work is cri-sis intervention. However, in psychiatric emergencies the pressure onboth patient and clinician is intensified because the potential for a dan-gerous and even fatal outcome can be high. The clinical setting maycontribute further to this pressure with large numbers of patients re-quiring assistance at the same time. As in the case of many emergencyrooms, the presence of a combination of psychiatric and medical emer-gencies is another complicating factor.

Many crisis services use "triage and assessment" as a means ofmanaging and sorting out the nonemergent psychiatric patients fromthose categorized as psychiatric emergencies. The process of triaginghas two primary purposes: (1) it reduces the patient's anxiety because itprovides an initial contact with a staff member who can provide reas-surance that he/she will be seen as soon as possible; and (2) it reducesstaff anxiety because triaging can provide for the prompt initiation ofan acute management program (e.g. psychopharmacological treatment)if necessary (Slaby et al., 1986).

Once the patient has been triaged as a psychiatric emergency, theprocess of assessment begins. Psychiatric emergency assessment is aspecialized form of crisis intervention assessment. The clinician must"cut through" to the most essential information for diagnosis and dispo-sition as quickly as possible without neglecting the patient's need to feelsupport and concern.

In the initial clinical interview, the first question to be addressed is"Why now?" What issues have impacted on the patient at this particu-lar time for him/her to seek help? As in all crisis intervention, consider-ation must be directed toward the individual's interpersonal system, so-cial matrix and internal psychodynamic status. If a problem complexappears at first glance to be merely a chronic situation, it is essentialthat the clinician probe the situation further to identify what the acuteprecipitant may be that prompted the individual to seek help at thistime. From there the clinician examines the nature of the current crisis,the patient's coping resources and what the patient's expectations are interms of his/her current request for help.

The interviewing clinician must address four basic tasks whenevaluating a patient who presents with symptoms suggestive of a psy-chiatric emergency: (Urbaitis, 1983)

1. Make a general or categorical diagnosis.2. Assess the severity of the problem and the behavioral disturbance.

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3. Assess the resources of the patient and family which might assistcoping.

4. Find a disposition.

To accomplish these tasks, the clinician must develop ongoing hy-potheses to account for the patient's distress and, as the interview prog-resses, test them by eliciting the necessary clinical material. During theinterview, the clinician must be alert for any significant changes in thepatient's ongoing physical and emotional demeanor so that immediateintervention can be provided to stave off any sudden danger, e.g. the pa-tient assaulting the interviewer or running off. The clinician must alsoexercise caution in the setting chosen for the interview, e.g. the type ofinterview room, collateral individuals present, or whether security orother backup staff members should be present.

The mental status exam is an important part of the psychiatricemergency interview because it can quickly elicit detailed informationin an organized way about the presence of symptoms and personalitytraits. Rather than concretely going down the official list of questions tobe covered, it is more productive to manage the mental status exam in aflexible manner according to the patient's clinical productions. Theseclinical findings may then be organized into certain clusters or groups ofsymptoms which can globally suggest certain syndromes or potential di-agnostic categories (Urbaitis, 1983).

Although there is usually intense pressure on the clinician to workrapidly, he/she must be careful not to give the patient short shrift in at-tention and time to tell his/her "story." At the close ofthe interview, theclinician should summarize conclusions drawn, reasons for such conclu-sions and recommendations for further care. Questions the patientmight have should be answered and any family members present shouldbe included if the patient agrees or if the situation warrants it evenwithout agreement (e.g. suicide, danger to others or if the patient is un-able to care competently for him/herself). Accurate record-keeping isalso extremely important because it provides a means of communicationabout the patient for future clinical use as well as providing legal pro-tection for the clinician and helping system.

There are numerous potential countertherapeutic pitfalls, espe-cially for the novice helper, inherent in the assessment of psychiatricemergencies. Although these pitfalls can occur in all crisis interventionpractice, the pressure and intensity of psychiatric emergency work in-creases the probability of one of these problems occurring. The mostcommon pitfalls are:

1. Inappropriately rescuing tbe client, or taking a directive stancewhen the client is capable of responding to a facilitative stance.

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2. Allowing a client's regressive dependency to get out of hand or im-plying, unrealistically, that such needs can be completely met bythe helper.

3. Getting drawn into a collusion with the client's version of the crisisbefore adequately exploring all angles, including significant collat-eral contacts.

4. Getting caught up in the client's panic and helplessness to thepoint of rendering feelings of impotence in the helper.

5. Jumping to conclusions too quickly or jumping in to take controltoo quickly.

6. Being too passive and nondirective.7. Ignoring or leaving unexplored: feelings, facts, lethality, or serious

symptomology.8. Being too timid or retreating from responsibility which can include

leaving loose ends or leaving referrals or follow-up to the client'sdiscretion.

Adequate training, self-awareness and the ready availability of su-pervision and consultation can help in anticipating, managing andavoiding the development of any of these pitfalls.

The next section describes the major clinical properties and inter-vention issues associated with the five most common types of psychiat-ric emergencies: organic illness, alcohol/drug abuse, suicide, violence/as-sault, and acute psychosis. Within the category of suicide, two cases arecompared and contrasted to illustrate how two patients presenting withthe same general type of psychiatric emergency can require very differ-ent clinical approaches.

FIVE COMMON TYPESOF PSYCHIATRIC EMERGENCIES

THE ORGANIC PATIENT

Organic mental disorders can be defined as mental conditions char-acteristically resulting from diffuse impairment of brain tissue functionfrom any cause (Rund & Hutzler, 1983). Because many organic illnessesinvolve psychiatric symptoms, the first distinction to be made is whetheran organic cause is contributing to the distress. Hall et al. (1981), for ex-ample, reported that 46 out of 100 patients admitted to a psychiatrichospital had medical illnesses that had been previously unrecognizedwhich were contributing to their psychiatric condition.

It is imperative that non-medical clinicians working in psychiatricemergency settings have some rudimentary knowledge of basic clues to

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a possihie underlying organic condition. Such clues include: an acute on-set of disturbance, a positive medical history, disorientation, a fiuctuat-ing level of consciousness or lahile affect, visual hallucinations, or a fallimmediately followed hy disturbed hehavior (Urhaitis, 1983). Organicpatients often present as psychiatric emergencies hecause their dis-turhed hehavior frequently includes comhativeness that is difficult tocontrol, poor judgment or impulse control, and hizarre thought pro-cesses. Other essential aids in diagnosis include history from relativesor friends, a good physical workup and any appropriate metaholic, toxi-cological or radiographic studies.

The Case of Mr. A.

Mr. A. was brought to the mental health crisis center by police following afrantic call from Mr. A.'s parents reporting that he had "exploded" and was inthe process of "tearing up the house." Mr. A., age 30, was an only child residingwith his parents for the past two years following several unsuccessful attemptsto hold a joh and live independently. The current explosive behavior could not beexplained by any clear precipitant. Upon careful questioning by the crisis socialworker, the parents revealed that Mr. A. had a history of seizure disorder andwas supposed to be on phenobarbital. Mr. A. stated he had not been taking hismedicine because he didn't have enough money for the prescription. He wasimmediately referred to the local county hospital emergency room who admittedhim to a medical unit for observation. Subsequently, it was discovered that hewas suffering from a temporal lobe tumor which was in all likelihood the causeof his sudden violent outburst.

The police hrought Mr. A. to the crisis center instead of a medicalfacility because his hehavior appeared to he "crazy," e.g. he was comhat-ive, out of control, confused. The first clues to the underlying organiccondition surfaced upon exploration of the patient's history which re-vealed he had a seizure disorder. At that point, referral to medical eval-uation was appropriately indicated. Identification of the primary or-ganic disorder does not automatically imply that a psychiatric and/orsocial disfunction is not simultaneously contrihuting to the patient'scurrent prohlems, and the presence of such prohlems must also he ex-plored.

DRUGS AND ALCOHOL

A large proportion of patients seen in emergency services have dis-orders related to the use of alcohol and/or drugs, requiring a multidisci-plinary approach of hoth medical and psychosocial intervention. Suchpatients may he intoxicated, in states of withdrawal, seeking drugs, oradmitted for an overdose. They range from the disheveled intoxicated

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alcoholic who staggers into the crisis service and retches in the recep-tion area to the well-dressed executive who, when deprived of his/herregular intake of cocaine for a few days, experiences withdrawal symp-toms.

Alcohol and drug ahuse are common complicating factors in cases ofassault, domestic violence, and accidents, and can he secondary to manypsychiatric and physical illnesses. Many individuals may also attemptto solve their emotional prohlems with street drugs, thus compound-ing the prohlems for individuals with major mental illnesses (Walker,1983). Either directly or indirectly, alcohol and drug ahuse can producedisturhed hehavior, emotional prohlems, and physical illness or injurythat can reach the proportion of an emergency. An additional complicat-ing factor is that suhstance ahusers may produce reactions of disgustand anger in treating clinicians which may he understandahle at times,but never therapeutic.

The most significant management prohlem in suhstance ahuse, par-ticularly alcohol abuse, is disruptive, dangerous hehavior. There are,however, effective strategies for containing such individuals. For exam-ple, Hackett (1978) suggests the following interventions: a show of force(including the use of security or police officers), a non-threatening inter-view, an offer of food and a comfortahle environment, sedation and anon-aggressive interviewer stance.

The Case of Mr. B.

Mr. B., 55 years old, staggered into the crisis clinic waiting room loudlydemanding that someone see him immediately. Although the intake technicianattempted to talk to him and guide him to a separate room where he could beseen, Mr. B. became angrier, demanding he be given service here and now.Fortunately, the waiting room was equipped with a silent alarm which thetechnician activated. This brought several staff as immediate backup. Uponseeing such a "show of force," Mr. B. became more cooperative and allowedhimself to be escorted into an examining room. Upon evaluation by the crisissocial worker, it was clear that Mr. B. was intoxicated from alcohol. Althoughcooperative, he remained irritable, had difficulty paying attention, and exhi-bited facial flushing, tremors and slurred speech. Because of his intoxication, itwas impossible for the clinician to explore the presence of other psychiatricproblems. It was decided that Mr. B. should be detoxed first and then referralcould be made back to the crisis clinic if needed. With gentle but persistentpersuasion Mr. B. allowed the social worker to place him in the detoxificationunit at the county hospital.

As in other organic conditions, if a patient arrives inehriated at acrisis service, the intoxication must he dealt with hefore any psychiatricintervention can commence. In this case, the very fact that Mr. B. cameto a mental health service as opposed to a medical facility might indi-

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cate he has concerns ahout emotional prohlems other than drinking.Until he is soher, however, it is impossible to explore this accurately.The crisis worker's decision to refer him immediately to detox is appro-priate. Once soher, the detox unit could request a follow-up psychiatricevaluation if indicated at that time.

THE SUICIDAL PATIENT

The evaluation and disposition of individuals presenting as suicidalcomprises a significant proportion of those seen in psychiatric emer-gency work, particularly in services that accept police referrals or haveambulances (Glick et al. 1976). Patients with the potential for suicideusually present as having attempted the act or as having given thoughtto it. In addition, accidents, suhstance ahuse and certain hehavior changesmay indicate underlying self-destructive intent.

Clinicians may view some suicidal patients as merely irritating ma-nipulators which is an attitude that can cloud good clinical judgment.Mutilating horderline patients are prime candidates for this phenom-ena. It is extremely important for the evaluating clinician to perform arigorous assessment and always document it thoroughly for hoth clin-ical and legal purposes. If the patient is intoxicated, psychiatric evalua-tion should not he completed until the patient is cleared from toxic ef-fects. Meanwhile, the clinician can perform essential interventions withupset family memhers or friends.

Usually the disposition choices for the suicidal patient come downto only 2 options: 1) discharging the patient to outpatient treatment anda social support system that will ensure safety; or 2) voluntary or invol-untary psychiatric hospitalization. Assessment of suicidal patients is ex-tremely draining for the clinician, and therefore adequate consultationand support in such cases is essential.

Below are presented two cases of suicidal patients who are similarin some ways hut who require very different clinical approaches. Bothpatients are diagnosed with horderline personality disorders, are sui-cidal and are struggling with a crisis precipitated hy a real or threat-ened ahandonment hy a love ohject, e.g. a source of support.

Patient #1, Ms. C, functions at what would he termed a "low level"(Masterson, 1976). She has a chaotic life style, ahuses alcohol and streetdrugs, and has a long history of acting out hehaviors, e.g. self mutila-tion, short jail terms for petty crimes, etc. Her thinking is concrete, shewon't stick with any kind of ongoing intervention and she is not psycho-logically minded. Emergency interventions with this type of patienttend to he limited in depth.

In contrast, patient #2, Ms. F., functions at a "high level." Showing

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up at an emergency room can he a rare occurrence for such a patientand is usually precipitated hy a specific stress that results in a re-gressed loss of control. It is not unusual for such patients to he involvedin ongoing therapy and therefore emergency interventions and followuparrangements must take must take this into account.

Patient #1: The Case of Ms. C.

Ms. C. is a 23-year-old woman who was brought to the county hospitalmedical emergency room via police for treatment of multiple superficial cuts onboth forearms. Police had been called by Ms. C.'s boyfriend who reported thatshe had cut herself after he told her that he wanted to end their relationship.Both Ms. C. and her boyfriend had been drinking. After her cuts were attendedto, the crisis center social worker was called to conduct an evaluation. Ms. C.was well known to the E.R. and the crisis center for a long history of self-muti-lating behaviors following upsets with her boyfriend or her mother with whomshe lives. Although routinely referred for counseling many times, Ms. C. hasnever followed through. Upon evaluation Ms. C. was irritable and uncooperativewith the interview. She would not contract not to harm herself, loudly demand-ing she be released so she could "take care of business." A phone call to hermother was not helpful, with the mother stating only that she was tired of herdaughter's behavior and "you people should lock her up." Hospitalization wasunder consideration but the boyfriend suddenly showed up at the emergencyroom and told Ms. C. he didn't want to break up after all. Delighted, Ms. C.announced she was no longer suicidal.

Patient #2: The Case of Ms. F.

Ms. F., a 25-year-old single white female, came to the emergency room of alocal private hospital demanding admission to their psychiatric inpatient unit.When the ER staff could not elicit any overt psychiatric symptoms, she was toldthat hospitalization was not indicated. Immediately Ms. F. became incensed andthreatened suicide. The ER doctor didn't feel their open psychiatric unit couldhandle Ms. F., stating that county mental health should evaluate her for hospi-talization at their locked facihty. When the county's crisis social worker, G.,arrived, her first intervention step was to take Ms. F. away from the bustle ofthe ER to an attached conference room where they could speak privately. Afterclearly identifying who she was and why she was there, the social worker con-fronted Ms. F.'s behavior, e.g. her arrival at the ER in no acute distress juxta-posed against her demand for hospitalization. Ms. F. responded: "Yeah, that'sthe same crap I get from my therapist." After some probing, Ms. F. revealed thatshe had been seeing "Dr. Mary Doe" three times a week for the past nine months.G. reflected to Ms. F. that she seemed to have some out of control feelings,asking her if she has had them before. At this, Ms. F. angrily stated that she feltthis way the last time her therapist went on vacation, adding that she was"pissed ofF' and "I just can't cope!" G. continued to challenge Ms. F. with herown statements, puzzling as to their meaning. Eventually Ms. F. began talkingabout how alone and abandoned she was feeling and about her anger that Dr.Doe wasn't immediately available. Eventually Ms. F. stated reluctantly that Dr.Doe had arranged for her to see a colleague during her absence. When G. in-

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quired as to whether Ms. F. had an appointment, Ms. F. replied "No because Dr.Doe (and her colleagues) are just a bunch of quacks." G. confronted this devalua-tion stating that if Ms. F. really thought Dr. Doe was a quack, she probablywouldn't have been seeing her three times a week for nine months, suggestingthat Ms. F. was feeling abandoned and angry at her therapist. Ms. F. concededthis and reiterated her fear of not being able to cope with her therapist's ab-sence. With G.'s encouragement, Ms. F. finally called and arranged for an ap-pointment the following day with one of Dr. Doe's colleagues although Ms. F."doubted that she'd need to keep it." Following this call, Ms. F. volunteered toG. that she no longer felt suicidal and wanted to leave so she could get home intime to watch "Falcon Crest" with her sister.

A crisis precipitated by loss and abandonment was the central issuefor both Ms. C. and Ms. F., but their responses to the crisis and theirability to utilize intervention differed greatly. Ms. F. possessed enoughinsight and psychological sophistication to respond constructively to thesocial worker's interventions and confrontations. Eventually she experi-enced relief from her suicidal feelings and a restoration of feelings ofcontrol.

Ms. C, on the other hand, is the type of patient that over timemakes most mental health clinicians, emergency room staff and policeboth angry and frustrated. Repeated threats of suicide followed by selfmutilating behavior along with not following through with counselingin spite of the best efforts by many professional helpers results in suchreactions. In contrast to Ms. F.'s ability to profit from confrontation ofher conflicts and thus regain control, Ms. C.'s suicidal feelings abatedonly when her loss was concretely restored via her boyfriend's change ofheart. Ms. C. showed no evidence of any desire, and probably had lim-ited ability, to work through her problems in counseling. Over time it isnot uncommon for such patients to be responded to eventually with res-ignation, callous lack of concern or even dislike by clinical staff. Under-standing and accepting the limitations of such a patient's psychologicalresources, however, can both maximize potential for a positive outcomeand prevent the intervener from becoming frustrated over unmet expec-tations. Again, it is imperative that emergency clinicians who workwith such patients have available good support and consultation fromcolleagues.

THE VIOLENT ASSAULTIVE PATIENT

A violent or aggressive patient can have a severely disruptive effecton the milieu of a psychiatric emergency service (Salamon, 1976). Clearknowledge of the therapeutic options for the management of such pa-tients is essential. Violent or potentially violent patients can be catego-rized as either self-referred or referred by others. The voluntary self-

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referred patient often complains of non-specific tension and fears thathe/she will lose control, what Beebe (1975) refers to as the "pre-assaul-tive crisis." If referred by others, usually police or family, the patientmay have already committed a violent act.

It is important to establish from the start that the patient is in amental health setting that will help, not punish, and that the efforts ofthe staff will be in his/her best interest. If the patient presents in re-straints, the restraints should remain until it is clear that control canbe maintained. Regardless of the patient's apparent state of mind, theclinician must always behave appropriately toward the patient, im-parting honesty, dignity and respect. Interventions should always be ex-plained clearly and firmly.

Potentially assaultive patients not in restraint should be inter-viewed in a quiet room, with security staff available. The clinicianshould avoid sitting between the patient and the door, and the doorshould be left open. As the interview progresses, if the patient's controlappears to be deteriorating, as evidenced by increased pacing or makingthreatening gestures, the clinician should communicate to the patientthat external controls will be enforced if necessary. If that assurancedoes not allay the patient's agitation, external controls (e.g. restraint,seclusion or medication) should be instituted without delay.

The Case of Mr. D.

Mr. D. is a 26-year-old single white male brought to the mental healthcrisis center by the police for evaluation. Police had been called to a local conve-nience store after Mr. D. had "shot up the place." When police arrived, he madeno attempt to escape and was observed to continue to verbally rage in the park-ing lot. Apparently he had gone to the store for some beer and when he couldn'tpay for it the clerk told him to put the beer back in the cooler. At that, Mr. D.exploded, pulling out a gun and firing randomly into the store. Nobody, fortu-nately, was hurt. When police approached Mr. D., he began to rant and raveabout everyone conspiring against him and other comments the police inter-preted as being possibly delusional. Upon evaluation at the crisis service, Mr. D.presented in handcuffs, leg irons and a neck iron. Because he appeared to be inmarginal control, the restraints remained. He was extremely guarded with thecrisis worker and absolutely refused to cooperate in the examination. Priorrecords revealed that Mr. D. had been diagnosed as paranoid schizophrenic andantisocial personality disorder with a long history of noncompliance with treat-ment. Surprisingly he was willing to take a shot of haloperidol and after anhour of observation became more cooperative with the evaluator. Final disposi-tion was involuntary hospitalization as a danger to others with a police hold fora transfer to jail upon discharge from the hospital.

Cases like Mr. D. are very difficult to evaluate and manage becauseof the combination of a major mental disorder and personality disorderalong with evidence of violent behavior. In addition, he was uncoopera-

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tive toward psychiatric evaluation. The best tack to take in such cases isto maintain protective measures, e.g. restraints and police, while tryingany available interventions which might elicit enough cooperation fromthe patient to determine a disposition. The choice here was to hospital-ize Mr. D. with the purpose of stabilizing his psychotic symptoms andthen to transfer him to jail where his criminal charges would be dealtwith.

THE ACUTELY PSYCHOTIC PATIENT

Psychosis is defined as a gross impairment of reality testing (Urbai-tis, 1983). Although some acutely psychotic patients seek help on theirown, most are brought to services by otbers, usually family, friends orpolice.

Assessment of tbe acutely psychotic patient must be rapid but care-ful. The major differential diagnosis is wbetber the etiology is organicor functional. In tbe interview, it is important to listen to the patientand sbow concern but not exbibit an overly solicitous attitude (Urbaitis,1983). With a hostile psychotic paranoid patient, the interview should beconducted in an open spacious room with backup staff nearby. Be tact-ful, do not ask too many questions and do not argue with delusions.

There are two major issues tbat can affect disposition: 1) whetherthe patient's delusional system consists of a threat tbat be must defendagainst whicb could include barm to self or others; and 2) wbether he ishearing command voices telling him to do harm to bimself or others. Ifso, then immediate bospitalization is usually indicated. Sometimes aless restrictive alternative can be acceptable if the patient is clearly co-operative in taking antipsychotic medication and J/" be/she has a strongresponsible support system. Often in such cases even voluntary bospi-talization is either refused by the patient or would not provide sufficientprotection. In tbat case, involuntary commitment is indicated.

Coping with an acutely psychotic family member or friend is ex-tremely taxing. It is important that the clinician be sensitive to familiesand/or friends, and support them in tbeir distress. In all likelihood tbeywill be continuing to cope with the patient and if they feel supported bytreatment personnel, the responsibility of sucb care will be less difficult.

The Case of Ms. E.

A psycbologist from the local university counseling service contacted thecounty mental health mobile crisis unit regarding an eighteen year old femalestudent, Ms. E. Ms. E. had been referred to the psychologist hy her dormitorydirector who reported that Ms. E. had suddenly become extremely paranoid but

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refused to get help. Due to Ms. E.'s resistance and the emergent nature of thesituation, the psychologist called the county mobile crisis unit for assistance.Ms. E. was a freshman, living several hundred miles from home. She had grownup in a very sheltered environment and had been quite anxious about her aca-demic performance during her first semester at school. During finals week shehad become increasingly withdrawn and irritable, refusing to leave her roomand finally accusing her roommate of tampering with one of her term papers.Upon evaluation in her dorm room by the crisis social worker, Ms. E. was ex-tremely paranoid, eventually revealing several delusions about her roommate,other students and her professors. Following a two week voluntary hospitali-zation at a private psychiatric inpatient unit, her symptoms cleared and withpsychotherapy follow-up she was able to stay in school and function fairly wellsocially.

Ms. E. suffered from an acute paranoid psychotic episode which wasprecipitated by the comhination of a basically fragile personality struc-ture plus stress experienced in association with some recent major lifechanges: beginning college, moving far away from home, and academicpressure. Her condition was severe enough for hospitalization to be indi-cated although involuntary measures were not necessary. The follow-uppsychotherapy was an essential element in enabling Ms. E. to resumeher previous level of functioning and avoid another hospitalization.

CONCLUSION

This article has outlined the basic practice principles of psychiatricemergency work along with descriptions and illustrations of five of themost common types of intense and stressful psychiatric emergencies.Such work requires a clear understanding of crisis intervention theoryand principles, and a thorough grounding in the specific practice princi-ples outlined above.

Psychiatric emergency work also entails unique tasks of coordina-tion and consultation, with a single case often simultaneously involvingseveral interested parties who may have contrasting agendas and in-puts. Such parties can include not only the patient, but family members,other therapists, medical personnel, law enforcement, and any otherswho have a direct or indirect interest in the case. Because it is an emer-gency, all these parties may converge at once, demanding an immediateresolution.

Because many professional schools do not mandate crisis interven-tion methods training, social work practitioners who end up working ata crisis service are at a disadvantage, as are their patients. Any kind ofhuman service work, however, may involve such crises from time totime. To avoid the necessity of always referring to someone else in such

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cases, the well rounded practitioner should have at least a rudimentaryknowledge of how to diagnose and manage some of these psychiatricemergency problems. Perhaps all master's level schools of social workshould require a one semester methods course in crisis intervention/psy-chiatric emergency work. Essential to such training, of course, is know-ing the limits of one's expertise and when it is advisable to refer or re-quest further consultation.

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