Mental Health Crisis Intervention in Emergency Departments

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. Internship experience at a county mental health screening center located inside a hospital emergency room—where patients from across the county are processed—offered a direct view of this gap. At that facility, patients are screened using the Columbia Assessment to determine whether they are currently suicidal, homicidal, or a danger to others. However, these patients are not offered counseling services. Instead, they are referred to outside resources or are voluntarily or involuntarily committed.

The lack of any other treatment is a serious problem. 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 many EDs there is no follow-up, and some clients return as often as once a week and still require evaluation. By not providing them with treatment beyond a list of resources to access on their own, facilities leave a significant gap in mental health services for the community. Clients are brought to the hospital via police, ambulance, school district referrals, nursing home referrals, or as walk-ins. The ER thus becomes a revolving door: clients are treated for chief complaints rather than for the underlying problem. This issue is directly relevant to social work because there is a pressing need to address the root concerns of this population so that the revolving-door dynamic can be broken and individuals can improve their lives.

Background and History

The problem of individuals not receiving proper care in the ER has emerged as a recognized concern for social work in recent years; however, it was present as far back as the 1970s, when Groner (1978) published a study describing an existing program so that others could understand the model. In more recent years, there has been greater emphasis on the need for solution-based interventions to be used in EDs rather than simply passing patients along without treatment (Kondrat & Teater, 2012). The target population for such interventions is the ER population presenting with issues of self-harm or suicidal ideation, or who may pose a threat to others. Past initiatives have focused on providing assessments like the Columbia Assessment, but more must be done in terms of follow-up care (Stanley et al., 2018).

In terms of multicultural practice, social workers must always possess cultural competence when working with individuals, because no two people are the same. Everyone has a unique background, set of experiences, beliefs, and cultural identity that should be understood before attempting to treat them. Leininger's transcultural model of care can be applied for this purpose. The central professional concern, however, remains that these patients are not receiving the help they need.

Individuals in this population who come to the ER and are assessed to be at risk for self-harm should receive additional care and specialized treatment precisely because they face a higher risk of suicide than the general patient population. Such a risk-reduction response would not be a reaction to any existing regulation but rather a response to the absence of proper interventions. This is a social work safety issue clearly exposed by the research literature. Any facility that does not address this risk by developing and implementing a strategy will be failing in its mission and not upholding its obligations to its patients.

One measure of how pervasive this problem is: currently, only approximately half of all Medicaid patients presenting to the emergency room for self-harm receive a mental health diagnosis before being discharged (Olfson et al., 2013). This statistic places half of all health care facilities in a precarious position with respect to their obligations to this population. If health care facilities and social workers are not providing these patients with the mental health assistance they require, they are failing in their core aim to deliver quality care to every patient who presents to them.

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