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, 2022).

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 referred to as chemical restraints) are implemented.

The primary goals of de-escalation are to help the distressed person reduce the intensity of their emotions and behavior quickly and effectively and to maintain the person’s safety as well as the safety of others in the area. In addition to reducing the intensity of the current situation, de-escalation also prevents further escalation of the problem (Ferlick, 2022).

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 arm’s lengths distance from the patient and maintain an unobstructed path out of the room for both the patient and staff.
Establish verbal contact. If possible, the first to contact the person should be the staff leader. Otherwise, designate one or limited staff members to interact with the person. Introduce self and staff and orient the person to place and what may be expected. Reassure the person 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 common, everyday language. Elaborate and technical terms are hard for an impaired person to understand.
Use active-listening skills. After listening, restate what was said to improve mutual understanding.
Set clear limits and expectations. Tell the patient that injury to self or others will not be allowed.
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.
Allow adequate time for processing. 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.
Be empathetic. 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:

Be provocative; instead, keep hands relaxed, maintain a nonconfrontational body posture
Stare at the person
Criticize the person
Argue with the person
Interrupt the person
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 & Moore, 2023)

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. Restraints and seclusion have no therapeutic value, cause human suffering, and frequently result in severe emotional and physical harm. They can also result in a person’s death. They are safety measures of the last resort. It is important to understand that restraint use is regulated by federal and state agencies.

Seclusion is the involuntary confinement of a patient alone in a room or area from which the person 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 person 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 person, a staff member, or others in the vicinity, and they must be removed as soon as the person and other persons in the vicinity are safe.

Restraints should not cause harm or be used as punishment. Other methods to control a patient and ensure safety should be tried first. 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, 2023; Dugdale, 2021).

SEDATION

Sedation with medication, formally 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 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.

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.

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.” The Code of Federal Regulations outlines conditions that must be followed when such restraint is used.

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 (Moore & Moore, 2023; CFR, 2023b).

RESTRAINT REGULATIONS AND REQUIREMENTS

According to the Joint Commission and the Centers for Medicare and Medicaid Services, there are many regulations and requirements that address restraints and restraint use, including:

The initiation and evaluation of preventive measures that can reduce or prevent the use of restraints
The use of the least-restrictive restraint when a restraint is necessary
Monitoring the patient during the time that a restraint has been applied
The provision of care to clients who are restrained

(See also “Resources” at the end of this course.)

CASE

Use of Restraints

Jerry, a known mental health patient with bipolar disorder, was admitted at 8:30 p.m. to the secure unit of the Mental Health Care Center under a 72-hour hold for evaluation. He had been brought in by the police because of his bizarre behavior in the local store, grabbing and shoving people toward an exit and shouting at them to “get out of here, right now! We’re under attack!” During the night, he was cooperative, but he remained agitated and argumentative.

In the morning, Jerry was taken by a psychiatric technician to the interview room for evaluation by the psychiatrist, the psychiatric nurse, and the social worker. Initially he was euphoric, grandiose, and very friendly. As the evaluation proceeded, he suddenly became more agitated. Verbal attempts were made to help him gain control, but at one point, he jumped out of his chair, ran to the psychiatrist, and punched him in the face. The psychiatrist fell backward in his chair and hit his head against the wall. The psych tech picked up the phone and dialed for a “Doctor Green.”

Using de-escalation techniques, the nurse and the social worker attempted to calm Jerry down verbally, but he became more belligerent and threatening and took several swings with his fists at the staff. In less than a minute, the five-member “Doctor Green” team arrived and took Jerry down to the floor. The team then made the decision to apply restraints based on the fact that Jerry was physically combative and a danger to others, unable to be subdued using de-escalation methods, and further delay in the use of restraints might subject other staff persons to the risk of harm.

The restraint gurney was brought in, and Jerry was placed on his back in four-point leather restraints. The head of the gurney was raised 30 degrees to avoid aspiration. While restraints were being applied, the team leader explained to Jerry what they were doing and why. The other four members of the team each applied a restraint to an extremity and made certain the devices were secured to the gurney frame and that circulation to the extremities was not compromised.

While Jerry was being restrained, the nurse assessed the patient for immediate first aid needs and called the medical staff to evaluate his status, while a second nurse assessed the psychiatrist whom Jerry had punched for immediate medical needs.

Jerry was taken to an isolation room, and within the hour, a member of the medical staff came to conduct a face-to-face evaluation of the need for restraints. Jerry continued to threaten harm to staff persons. Following the assessment, an order was written for restraints to be used for the maximum of four hours per Joint Commission standards.

A psychiatric nurse was assigned to remain in the room with Jerry to continually assess, monitor, and reevaluate him for the continued need for restraints.