Lack of Mental Treatment and Support
Introduction and Overview

Emergency departments (EDs) can play a major role in reducing the risk and occurrence of suicide, self-harm and harm caused to others by taking steps to create a safety plan for the patient (Stanley et al., 2018). However, many EDs do very little to actually assist patients in this regard. My own experience at Legacy Treatment Center, where I interned, allowed me to see as much. Legacy is in Lee County’s Screening Center for Mental Health Crisis and is located inside Main St Hospital, and patients from all over the county are processed through the Emergency Room. At Legacy, patients will be screened using the Columbia Assessment to see whether they are currently suicidal, homicidal or a danger to others. However, these patients are not offered counseling services. Instead, they are referred or voluntarily or involuntarily committed. The lack of any other treatment is a problem because as Olfson, Marcus and Bridge (2013) point out, “each year in the United States, roughly two-thirds of a million patients present to emergency departments for the treatment of deliberate self-harm” (p. 1442). These patients are, moreover, at an elevated and very high risk of suicide (Cooper et al., 2005). Yet at Legacy and many other EDs, there is no follow up, and some clients return once a week and still need to be evaluated. By not providing them with treatment other than resources for them to access on their own, it leaves a huge gap in mental health services for the community. Clients are brought to the hospital via the police, ambulance, referred from the school district, nursing homes or come as walk-ins. The ER becomes a revolving door and clients are treated for chief complaints and not for the underlining problem. The issue is relevant to social work because there is a need to address the underlying concerns of this population so that the revolving door situation can be overcome and the individuals can improve their lives.

Background/History

The issue of individuals not receiving proper care at the ER has emerged as a concern for social work in recent years; however, the issue was present as far back as the 1970s when Groner (1978) published his study and provided description of an existing program for others to understand. However, in more recent years there has been more emphasis on the need for a solution-based intervention to be used in EDs instead of simply passing these patients along without treating them (Kondrat & Teater, 2012). The target population for this intervention is thus the ER population presenting with issues of self-harm or suicide or who may present as a threat to others. Past initiatives have focused on providing assessments like the Columbia Assessment but more needs to done in terms of follow-up (Stanley et al., 2018). In terms of multicultural practice issues, social workers always need to possess cultural competence when dealing with individuals because no two people are going to be the same, and everyone has a unique background, set of experiences, beliefs and culture that should be understood before attempting to treat the person. Leininger’s transcultural model of care can be used for this purpose. The current major social and professional concern is, however, that these patients are not getting the help they need.

Individuals of this population, who come to the ER and are assessed to be at risk for self-harm, should receive extra care and special treatment because of the fact that they are at higher risk for suicide than other patients. Such a risk reduction response would not be a response to to any existing regulation but rather to the lack of proper interventions in place. This is a social work safety issue that the research has exposed for this particular population. If Legacy does not address the risk by developing and implementing a strategy, it will be failing in its mission and not upholding its vision for itself and its patients.

One example of how pervasive this problem is can be seen in the fact that, currently, only approximately half of all the patients who are on Medicaid receive a mental health diagnosis before being discharged when reporting to the emergency room for self-harm (Olfson et al., 2013). This statistic essentially puts half of all health care facilities in a risky situation with regard to failing to help this population. If health care facilities and social workers are not providing these patients with the mental health assistance they require, they will be failing in their aim to provide quality care to every patient who presents to them.

Theory

The theory that best explains the issue is that provided by Burnette, Ramchand and Ayer (2015) who state that people on the front lines of health and human services can be seen as gatekeepers who can prevent suicide, self-harm or harm to others by having knowledge of the mental health issue, understanding that this conduct is preventable, being mindful of the stigma that goes around, and having he self-efficacy to intervene. The problem that care providers and social workers see is that there is not enough training in place and no tool for treatment this mental health issue in the ER. This theory influences my thinking about how to intervene to alleviate the problem in the sense that those in the ER need more training about the issue, more knowledge that suicide can be prevented, and a better tool for intervening.

Literature Review

Contributing scholars on this area tend to be operating in health care relating fields but Groner (1978) set the stage for showing the need for a proper assessment. At this point, however, researchers are looking at what more can be done than a simple assessment like what is currently used in most ERs. The lack of assessment tools is not a problem as there are numerous tools available for physicians and social workers to assess patients and predict the likelihood of future suicidal behavior. There is the Columbia Suicide Severity Rating Scale (C-SSRS), the Patient Safety Plan Template, and the Safety Plan Treatment Manual to Reduce Suicide Risk. The overall aim that researchers say should be sought is to improve access to mental health assessments that provide help for these patients in the emergency department (Olfson et al., 2013). Three strategies for improving that access are:

1. training emergency department staff to provide...…person, focuses on beneficence, and promotes justice, the problem is only going to worsen.

As Stanley et al. (2018) have shown, their intervention does help to reduce the risk of suicide for patients who present to ERs with mental health issues. Their intervention should thus become a staple of ER policy and intervention. Training can be conducted in a simple manner, according to the developers of the intervention. The training steps are:

1. reading the safety plan manual by Stanley et al. (2018),

2. reviewing the brief instructions and the safety planning form;

3. attending a training in which the intervention, its rationale and evidence base are described; and

4. conducting role-plays to practice implementing the intervention (Safety Planning Intervention, 2019).

The resources needed for this training are the safety plan manual, which can be obtained from http://www.suicidesafetyplan.com/Training.html. A training room and practice intervention session will be required in which trainees get to role play implementing and receiving the intervention. This is a form of simulation that gives the care providers extra assistance in learning how to conduct the intervention. The trainer, presumably the head nurse or instructor nurse at the ED, or social work leader, will require the rationale and evidence base provided by Stanley et al. (2018) to assist with the instruction phase of the training.

To measure the effectiveness of this policy, a statistical percentage of patient-suicide rate should be obtained similar to what Stanley et al. (2018) did for their longitudinal study when they tested their intervention on 1200 patients over the course of several years following the intervention to see what the success rate was based upon the decrease in suicide rates per patients who received the intervention. Data would be analyzed by conducting a simple percentage analysis and comparing it to the baseline and trend line that existed prior to the intervention.

Conclusions

The risk of suicide for patients presenting at the ED is one that has received attention recently by researchers, particularly Stanley et al. (2018). Patients who visit the ED but fail to receive the care they require should not be discounted by the hospital but rather should be considered as they are an example of the type of population most vulnerable to death and therefore most in need of assistance. If the statistics indicate that there is a national problem in the area, then it is more than apparent that it is a risk that needs to be addressed. Part of quality care is preventive medicine and the intervention proposed by Stanley et al. (2018) is an excellent example of preventive care that a risk manager should be able to identify and recommend as a suitable intervention. Too many patients who present with mental health problems are not receiving the type of intervention and quality care they require—not there or anywhere nationally. Thus, in order to help reduce the risk of suicide for these patients, an intervention is needed that will be preventive in nature and facilitative in practice. An appropriate intervention to use with respect to this issue would be the Safety Planning Intervention developed and tested by Stanley et al. (2018).