This paper examines the critical gap in mental health treatment for patients who present to emergency departments (EDs) with self-harm, suicidal ideation, or risk of harm to others. Drawing on internship observations and a review of empirical literature, the paper argues that standard ED practice—typically limited to a Columbia Assessment followed by referral or commitment—is insufficient for a population at elevated suicide risk. The paper reviews three evidence-based strategies for improving care, with particular focus on the Safety Planning Intervention developed and tested by Stanley et al. (2018). It also addresses relevant policy principles drawn from the Belmont Report, multicultural practice considerations, and concrete steps for staff training, implementation, and outcome measurement.
The paper demonstrates evidence-to-practice bridging: it synthesizes empirical findings from multiple studies and translates them into a specific, step-by-step intervention protocol with a realistic implementation and evaluation plan. This technique—moving from "what the research says" to "what practitioners should do"—is central to applied social work scholarship.
The paper opens with an overview of the problem observed in a real clinical setting, followed by a historical background section that traces the issue from the 1970s to the present. A brief theoretical framework (gatekeeper theory) anchors the literature review, which evaluates three competing intervention strategies. The Interventions section details the Safety Planning Intervention step by step. The Policy section applies Belmont Report principles and addresses stigma. A short conclusion synthesizes the argument and reaffirms the recommended intervention. References follow APA format throughout.
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.
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.
The theory that best explains this issue is put forward by Burnette, Ramchand, and Ayer (2015), who argue that people on the front lines of health and human services can be understood as gatekeepers who can prevent suicide, self-harm, or harm to others. Effective gatekeeping depends on having knowledge of the mental health issue, understanding that such conduct is preventable, remaining mindful of the stigma that surrounds mental illness, and possessing the self-efficacy to intervene. The problem that care providers and social workers encounter is that there is insufficient training in place and no standardized treatment tool for addressing this mental health issue within the ED context. This gatekeeper theory informs thinking about intervention by clarifying that those working in ERs need more training about suicide risk, greater awareness that suicide is preventable, and a better tool for intervening when patients present in crisis.
Contributing scholars in this area tend to work in health-care-related fields. Groner (1978) set the stage by demonstrating the need for a proper assessment process. At this point, however, researchers are examining what more can be done beyond the simple assessments currently used in most ERs. A lack of assessment tools is not itself the problem, as numerous tools exist for physicians and social workers to assess patients and predict the likelihood of future suicidal behavior. These include the Columbia Suicide Severity Rating Scale (C-SSRS), the Patient Safety Plan Template, and the Safety Plan Treatment Manual to Reduce Suicide Risk. The overarching aim articulated in the literature is to improve access to mental health assessments that provide meaningful help for these patients in the emergency department (Olfson et al., 2013). Three strategies for improving that access are:
Each of these strategies is viable, as Olfson et al. (2013) point out. Training emergency department staff to provide mental health assessments and deliver acute care for self-harm is well within the capacity of ED personnel, and tools to support that process have already been developed. Equally, as Callaghan et al. (2003) note, offering a liaison service to mental health specialists would be feasible and consistent with the existing mandate of emergency room staff. The third option—integrating mental health services directly into the ED's own operations—is also promising, though its practicality depends heavily on budgetary constraints (Browne et al., 2011).
The empirical literature strongly supports the need for an intervention beyond the Columbia Assessment. With roughly 660,000 people presenting to ERs annually in the United States for self-harm, the scale of the problem is substantial (Olfson et al., 2013). Because only half of those patients receive an appropriate mental health diagnosis before discharge, the urgency of the issue is clear (Olfson et al., 2013). Furthermore, 80% of persons who die by suicide had presented themselves to an emergency room for self-harm at some point during the year prior to their death (Chatterjee, 2018). This figure alone demonstrates that a more robust intervention is desperately needed.
Appleby, L., Morriss, R., Gask, L., Roland, M., Lewis, B., Perry, A., ... & Davies, L. (2000). An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project). Psychological Medicine, 30(4), 805–812.
Belmont Report. (1979). Ethical principles and guidelines for the protection of human subjects of research. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Department of Health, Education, and Welfare. Retrieved from
Browne, V., Knott, J., Dakis, J., Fielding, J., Lyle, D., Daniel, C., ... & Virtue, E. (2011). Improving the care of mentally ill patients in a tertiary emergency department: Development of a psychiatric assessment and planning unit. Australasian Psychiatry, 19(4), 350–353.
Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. RAND Health Quarterly, 5(1).
Callaghan, P., Eales, S., Coates, T., & Bowers, L. (2003). A review of research on the structure, process and outcome of liaison mental health services. Journal of Psychiatric and Mental Health Nursing, 10(2), 155–165.
Chatterjee, R. (2018). A simple emergency room intervention can help cut suicide risk. Retrieved from https://www.npr.org/sections/health-shots/2018/07/11/628029412/a-simple-emergency-room-intervention-can-help-cut-future-suicide-risk
Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., & Appleby, L. (2005). Suicide after deliberate self-harm: A 4-year cohort study. American Journal of Psychiatry, 162(2), 297–303.
Groner, E. (1978). Delivery of clinical social work services in the emergency room: A description of an existing program. Social Work in Health Care, 4(1), 19–29.
Jackson, K. (2019). Suicide prevention is every social worker's business. Social Work Today, 19(1), 1–10.
Joe, S., & Niedermeier, D. (2008). Preventing suicide: A neglected social work research agenda. British Journal of Social Work, 38(3), 507–530.
Kondrat, D. C., & Teater, B. (2012). Solution-focused therapy in an emergency room setting: Increasing hope in persons presenting with suicidal ideation. Journal of Social Work, 12(1), 3–15.
Olfson, M., Marcus, S. C., & Bridge, J. A. (2013). Emergency department recognition of mental disorders and short-term outcome of deliberate self-harm. American Journal of Psychiatry, 170(12), 1442–1450.
Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900.
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