FOREWORD: Creating a Secure, Safe Environment in Psychiatric Emergency Services

By Eliza AthansHealth Humanities, Special Issue: ER Observations, 2019



In this foreword to observation articles by Arendas, Barbour, Burri, and Wheless, Eliza Athans writes about the efforts that go into creating positive psychiatric enviornments and making psychiatric services feel safe.


Our society’s awareness of mental health has increased greatly over the past twenty years, but, sadly, psychiatric services found in emergency departments have not evolved in the same manner. Today, these emergency departments seem outdated in their efforts to treat psychiatric conditions. However, putting more effort to transform the typical environments found here could be the key to weakening the stigma surrounding psychiatric departments.

Psychiatric emergency departments function in a different manner than most emergency departments. The constant hustle and bustle that is associated with emergency departments is often not found, unless needed to control or calm a patient during a behavioral emergency. Instead, it is mainly comprised of a locked and guarded section of the hospital, complete with about a dozen beds, white walls, fluorescent lights, and patients who stay for much longer periods of time than typical emergency room visits. Since there are limited opportunities for patients to get long-term psychiatric care, the use of psychiatric emergency services is increasing every day.

In 1955, over 560,000 patients were cared for in state psychiatric facilities, but this number has drastically dropped to only 45,000 over the past 60 years (Sisti, Segal & Emanuel, 2015). Sisti, Segal, and Emanuel reveal that when considering our population in the US has doubled since then, this has resulted in a 95% decline in the number of beds available for those seeking long-term psychiatric care. Mental institutions were quite common throughout the twentieth century, though almost all of them were permanently closed during the latter half of the 1900s. These institutions were often viewed as frightening and had an abundance of negative stigma associated with them; however, they played a vital role in providing long-term psychiatric care for patients.

Psychiatric emergency departments treat patients with many different conditions, the most common being: schizophrenia, bipolar disorder, autism, dementia, depression, and substance use disorder (Nitkin, 2018). The prevalence of these conditions is increasing, average ages of patients are going down, and the lack of long-term care for these patients is not changing any time soon. When state psychiatric facilities were closing in the late 20th century, President Jimmy Carter signed an act that provided grants to community mental health centers to counteract the closing of said services (Amadeo, 2019). Around this time, it was found that a large majority of the individuals in psychiatric hospitals could function and do well in a community (Raphelson, 2017). These patients could be discharged with ease, continuing to attend therapy and support groups within their community as needed to treat their conditions. This has been successful for some, especially those with high-functioning cases of downs syndrome or autism, however, many people need a more structured, constant form of care. Raphelson explains how this disappearance of psychiatric hospitals has led to a mental health disaster, as patients have no other option than the emergency departments for psychiatric treatment, disrupting their efficiency as they are not organized to provide that type of treatment.

These individuals take up space in the emergency departments where room is already extremely limited. After their first admission, it is quite common to observe some “heavy user” patients make multiple annual trips for several years in a row; this limits the number of inpatient beds for the public and does not allow doctors to discharge patients appropriately (Surles & McGurrin, 1987). These emergency departments transform into holding areas or short-term acute outpatient treatment settings for the patients awaiting other psychiatric care, neither of which they are equipped to do (Surles & McGurrin, 1987).

Additionally, it has been found that many psychiatric emergency departments fail to meet the criteria for safety and privacy of patients as recommended by national psychiatry services. Through a volunteer study conducted in the United Kingdom, we learned that only 85% of participating hospitals had a psychiatric assessment room, and only 23% of these rooms met all criteria to protect the safety and privacy of patients (Bolton, Palmer & Cawdron, 2016). The responses of the study showed common themes: any extra rooms were used for extra storage or patient waiting areas, and most psychiatric emergency departments had very limited space, not allowing patients to move around if restless, which is an easy solution when dealing with emergencies. Even in the United Kingdom, one of the first highly developed countries in the world, there still seems to be little focus on mending these “healing” environments.

As mentioned, emergency rooms are often small and cramped spaces, where staff and patients are constantly moving. What is not commonly discussed, however, is the white bleakness that often is present in psychiatric emergency rooms. Individuals most commonly characterize emergency departments with feelings of loneliness, intimidation, fear, and discomfort (Shattell et al., 2013). Bright fluorescent lights, white walls and linens, cream tiles with few windows, if any, all create an inhospitable environment, certainly not the surroundings that encourage long-term recovery. A contrasting environment, one filled with natural light, colors, and things that embody what one’s home feels like would be a much more effective recovery-oriented alternative. One study tested the effectiveness of this sort of environment; named “The Living Room” the main space was designed to look similar to someone’s actual home (Shattell et al., 2013). The Living Room was equipped with a counselor, a nurse, and three peer counselors, and operated from 3-8pm for three days a week. When research participants were asked to describe the design of the setting, common themes were also found here: A Safe Harbor. A Helping, No Judging Zone. The Living Room was an area where patients and staff felt safe, like they could let their guard down, and ultimately focus on long-term recovery. If one is placed in a white-walled, guarded psychiatric department, they often feel as though they are prisoners. Altering their surrounding environment would change this mindset, making them feel as if they are still themselves throughout this process, while ultimately focusing on their recovery and wellness.

Changing the environments surrounding patients is a proactive solution that could be implemented in hospitals to decrease behavioral emergencies. One additional way of lessening these emergencies is the way by which staff members react to them. Behaviors like yelling, demanding, cursing, acting out, etc., pose risk to both staff members and other patients, but they are almost always expressed by patients in these emergencies (Zicko, Schroeder, Byers, Taylor, Spence, 2017). Staff members who are not knowledgeable on how to handle these situations often make matters worse by talking loudly back to patients or putting them in restraints. A violence safety program was tested in a New York City hospital and aimed to reduce the use of restraints and seclusion throughout the psychiatric department (Sullivan, Barron, Curley-Casey, 2005). The participating units actively learned and utilized alternative interventions to the best of their ability, however, the success (few instances when restraints/seclusion had to be used) of these units varied from unit to unit. For example, unit B, showed the greatest decrease in the use of restrain and seclusion, as they truly took on the challenge of reducing these numbers, and saw it as a treatment and team failure when they had to be used (Sullivan, et al., 2005). Other units who did not deem place the same emphasis on the effort of decreasing the use of these methods showed small success rates, proving that if staff members do not value the alternative methods, no success would be found. With so many unique cases coming through, no one patient can be treated the same. Staff often resort to using restraints when patients become too much to handle, but this does not help their recovery in any way.

The lack of value or importance placed in psychiatric emergency departments may be due to the negative stigma surrounding the specialty. These negative connotations have been around for years, beginning with the introduction of asylums that housed deranged individuals, causing people to misread those with mental health issues. Today, similar blemishes are present in psychiatric departments as some patients admitted do not even need services and only come to seek prescriptions or refuge. The presence of these individuals steals the focus away from those who actually need treatment. Others individuals instead need another more stable and routine type of care and would be better suited in a long-term mental facility. The function of psychiatric emergency services is often different from the perspective of staff compared to the perspective of a patient, and helping patients become aware of this can help staff better assist them when dealing with the complicated medical system.

As the patient demographics of psychiatric emergency departments change, the services offered must also evolve. The number of young people using the emergency room for psychiatric care has skyrocketed in the last twenty years with nearly twenty five percent of young patients admitted showing characteristics that allow them to be diagnosed with at least one mental health disorder. (The Lancet, 2016). Psychiatric services are, if not already, going to be at record high demand, and the system must be updated in order to provide safe, helpful treatment for these individuals in the years to come.

As the population that suffers from mental health conditions increases every day, we owe it to those individuals to update psychiatric services to provide safe, secure environments where they can ultimately focus on their long-term health. This may be accomplished by updating staff training so healthcare providers are more knowledgeable in how to respond to behavioral emergencies, changing the areas in which patients are housed to offer a more hospitable environment, or simply allotting more importance to the psychiatric specialty as a whole. Connected to this foreword are four stories by Barbour, Arendas, Burri, and Wheless, that illustrate their own experiences while spending time in the psychiatric emergency departments here in Chapel Hill.



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Eliza Athans