MENTAL HEALTH EMERGENCY BEHAVIOR MANAGEMENT

A mental health emergency is considered a life-threatening situation. The person may be imminently threatening harm to self or others, severely disoriented or out of touch with reality, functionally disabled, or extremely distraught and out of control.

Such aggressive, violent patients are often psychotic or have substance use issues, but it must never be assumed that the cause of the behavior is a mental disorder or intoxication, including for those patients known to have a psychiatric disorder or an odor of alcohol on their breath.

During such emergency crises, management and evaluation must occur simultaneously. Often these patients are unable or even unwilling to provide a clear history, and other sources must be found and consulted as rapidly as possible. This might include family members, friends, therapists or caseworkers, and medical records. Confidentiality is waived during psychiatric or medical emergencies, allowing for collection of such collateral data (USDHHS, 2020).

When working with an agitated and/or aggressive person there are five main goals:

• Prevent violent behavior
• Maintain the safety of the patient, healthcare personnel, and others in the area
• Avoid the use of restraints
• Improve patient-personnel connections
• Enable patients to manage their own emotions and to regain personal control
  (Daum, 2019)

De-escalation

The first step in responding to mental health emergencies is to attempt de-escalation. De-escalation is a combination of strategies, techniques, and methods intended to reduce a patient’s agitation and aggression. Nearly all patients who present with agitation or violent behavior should be given the chance to calm down in response to verbal techniques before physical restraints or sedation with medication (formerly chemical restraint) are implemented.

When a patient is unable to control emotions or behaviors, the following de-escalation techniques have been found to be frequently successful in less than five minutes.

• Remove from stimuli. The physical environment can make a patient feel threatened and/or vulnerable. Removal from a noisy environment to a quieter space helps reduce a patient’s stress and frustration.
• Respect personal space. Remain two arms’-length distance from the patient and maintain an unobstructed path out of the room for both the patient and staff.
• Set clear limits and expectations. Tell the patient that injury to self or others will not be tolerated.
• Minimize provocative behavior. It is important to remain calm and to speak in a calm voice. Movements should be slow, and actions should be announced prior to initiating them. Avoid touching the person unless asking permission first. Posture and behaviors can make a patient feel threatened and/or vulnerable, so a calm demeanor and facial expression should be maintained. Keep hands visible and unclenched, as concealed hands might imply a hidden weapon. Avoid confrontational body language such as hands on hips, arms crossed, directly facing the patient, and continuous eye contact.
• Establish verbal contact. If possible, the first person to contact the patient should be the staff leader. Otherwise, designate one or limited staff members to interact with the patient. Introduce self and staff and orient the patient to the emergency department or facility and what is to be expected. Reassure the patient that they will be helped. Recognize that the person in the midst of a mental health crisis emergency may be unable to clearly communicate thoughts, feelings, or emotions.
• Use concise and simple language. Agitated patients may be impaired in their ability to process information. Repeating the message and allowing adequate time for the patient to respond can be helpful.
• Use active-listening skills. Identify feelings and desires. Listen attentively and empathize with the person’s feelings. (See also “Crisis Intervention Communication” earlier in this course.)
• Agree or agree to disagree. Use fogging, an empathic technique in which one finds something about the patient’s position upon which to agree. (See also “Crisis Intervention Communication” earlier in this course.)
• Collaborate. Use a collaborative approach with the goal, of helping the patient calm themself.
• Offer choices and optimism. Realistic choices aid in empowering the patient to regain control and feel like a partner in the process.
• Do not:
  • Criticize the patient
  • Argue with the patient
  • Interrupt the patient
  • Respond defensively
  • Take the patient’s anger personally
  • Lie to the patient
  • Make promises about something that may not happen
• Debrief the patient and the staff. If an involuntary intervention is indicated, debriefing may help restore the working relationship with the patient and help staff plan for possible future interventions. Debriefing should involve an explanation as to why the intervention was necessary, and the patient should be asked to explain their perspective of the event. Options or alternative strategies should be discussed with the patient and with staff should the situation arise again.
  (Moore & Pfaff, 2020; Daum, 2019)

De-escalation, when effective, can avoid the need to use restraints. It is important to remember that taking the time to de-escalate the patient and working collaboratively as the patient settles down is more humanizing and much less time-consuming than placing the person in restraints, which requires additional resources during the application and during the period following application.

Restraints and Seclusion

Initial management should include use of the de-escalation techniques described above. But when people in crisis become so distressed that they are a danger to themselves or others, it may be necessary to place them in restraints or to isolate them.

Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is prevented physically from leaving. It may be used only for the management of violent or self-destructive behavior.

A restraint is any manual method, physical or mechanical device, material, equipment, or use of medications against the person’s will that immobilizes the patient or reduces their ability to move arms, legs, body, or head freely. Restraints may only be used to ensure the immediate physical safety of the patient, a staff member, or others in the vicinity, and they must be removed as soon as the patient and persons in the vicinity are safe.

Seclusion and restraints are safety measures of last resort and not treatment interventions. Restraints and seclusion do nothing to relieve the patient’s emotional suffering, they do not change behavior, and they do not help people with serious mental illness to better manage the thoughts and emotions that trigger behaviors that can injure themselves or others (MHA, 2020; Dugdale, 2019).

SEDATION

Sedation with medication, often referred to as chemical restraint, is defined as a drug or medication, or a combination, used as a method for managing a person’s behavior, restricting the person’s freedom of movement, or impairing the patient’s ability to appropriately interact with their surroundings.

Chemical restraint, however, is now considered a historical concept, and is not standard treatment for the patient’s underlying condition. Today there is an understanding that medications are instead used to treat the condition of agitation and its underlying causes, not for restraint (Zeller, 2017; Moore & Pfaff, 2020).

Sedation with medications may be necessary, with or without physical restraints, and rapid tranquilization may be required in the agitated or violent patient who does not respond to verbal de-escalation techniques. Rapid tranquilization may be required in the severely agitated or violent patient.

Drugs often used for sedation include benzodiazepines, antipsychotics, and dissociative anesthetics. However, currently there are no drugs in the United States that are FDA-approved for use as “chemical restraints.”

Because the use of medications for purposes of restraint is not standard treatment for the patient’s condition, many hospitals have come to include in their bylaws that they never utilize “chemical restraints” in their institutions. Instead, they only prescribe appropriate medications indicated in specific clinical conditions.