January 2019, Volume XXXIII, No 10

Behavioral Health

Mental health in the emergency room

A role for the medical family therapist

ontemporary efforts to integrate behavioral health care with biomedical services in primary care environments are advancing quickly. As evidence supporting such efforts grows, scholars and practitioners alike are beginning to the consider the utility of doing this in secondary care contexts as well. Emergency medicine represents an especially timely arena to do this, insofar as the intersections of mental—and physical—care needs therein are incontrovertible. The complexity and variety of cases that present in emergency rooms (ERs), however, can make balancing these foci a considerable challenge.

Emergency rooms’ presentations and culture

Patients’ and families’ emotional responses to the acute physical presentations that characterize ER visits are remarkably diverse. Common themes relate to struggling with ambiguities about what will happen to sick or injured patients, fears about one’s own or a loved one’s life and survival, and/or misplaced anger directed at each other, health care providers, or administrative staff. Behavioral health presentations per se—without clear physical components—are also common. Suicidality (and the severe depression that often accompanies suicidal thoughts), anxiety and panic, psychosis, and any myriad of other states defined by psychological decompensation can bring patients to emergency care. Moreover, the worries and fears maintained by family members who bring them in can echo those that we see in response to straightforward physical injuries or conditions.

Families are of remarkably high importance in emergency care.

ERs also do not serve or prioritize patients and their families in a first-come, first-served, manner, attending, instead, to those with the most acute and/or life-threatening conditions first. It is thereby possible that some (or many) patients have to wait a long time before being seen. These patients are at risk of experiencing prolonged discomfort, anxiety, worries, and anger. In addition, providers may (and do) also experience frustration and distress when patients with critical health conditions do not receive care in a timely manner. Patients, families, and providers may experience negative psychological symptoms as they navigate treatment processes sans mental health services and/or behavioral health colleagues.

Background and rationale

When family members experience emotional symptoms in ERs, they receive limited (or no) services, because providers characteristically focus most of their attention on the identified patient. Nursing studies—like those published in the Journal of Nursing Scholarship (Anderson & Tomlinson, 1992) and the Journal of Advanced Nursing (Tomlinson, Peden-McAlpine, & Sherman, 2001)—provide evidence that families are of remarkably high importance in emergency care for child and adolescent patients—but that providers are often not adequately trained to engage them in the provision of systemic interventions during and/or after a health crisis. Studies in social work—like Auerbach and Mason’s (2010) account in the journal entitled Social Work in Health Care—highlight the value of support services for patients and families in ERs in admissions and discharge planning—but not during acute care sequences and/or decision-making immediately within these timeframes.

Meeting patients’ and families’ needs in emergency medicine

According to scholars such as Nikki, Lepistö, & Paavilainen (2012) and Salminen-Tuomaala (2018), published in outlets like International Emergency Nursing and the Scandinavian Journal of Caring Sciences, patients and their families have expressed the following needs related to treatment in ERs:

  • Expecting more psychological support
  • Wanting loved ones to receive information about patients’ health conditions
  • Assistance in regulating emotions and decreasing anxiety while waiting for and receiving care
  • Wanting to be active participants in health care services and/or decision-making processes

Effectively meeting these needs will require a systems-informed (e.g., biopsychosocial/spiritual) approach that purposefully engages individuals within the contexts of the multiple systems that they inhabit, and that attends to the manners in which patients, families, and other systems mutually influence each other.

Medical Family Therapists (MedFTs) can provide a systemic orientation for patients and their families. Emerging scholarship—like that advanced by Kassekert and Mendenhall (2018) in Clinical Methods in Medical Family Therapy—situates such applications of clinical engagement across a 5-level continuum, with varying (and increasing) attention to integrated care provision, training/supervision, research, and policy efforts. Said work is, however, still in its infancy and is secondary to political impasses between sibling disciplines’ governing boards, payment models, and guild cultures that tend to exclude family therapists from practicing in emergency contexts.

MedFTs are able to work at the microsystem level.

A call to action

While there has been some attention paid to the integration of mental health services into emergency medicine, little has been written about this as it relates to providing family-based care. Family therapists can bring into these contexts advanced skillsets in systemic assessment (e.g., suicidality, homicidality, alcohol/drug abuse/dependence, interpersonal violence, couple/family communication, and problem solving), de-escalation sequences (e.g., angry/enraged patients or family members, disruptive waiting-room events), engaging police/security (e.g., in concomitance with de-escalation sequences), delivering bad news (e.g., a tragic laboratory result, death notifications), coordinating referrals (e.g., long-term behavioral health care, psychoeducation, social services), and team efforts to reduce and/or mitigate burnout and compassion fatigue through Balint groups of clinicians who meet regularly to present and discuss cases, staff huddles, individual/group debriefings, hallway consultations, and more.

In addition to helping patients and families, MedFTs can support health care providers to manage their stress and frustration, and to share their insights and systemic understanding of families’ experiences. MedFTs are able to work at the microsystem level to support patients’ and families’ relationships across care journeys (e.g., facilitate functional conversations between family members to manage stress and make effective care-related decisions). At the mesosystem level, they can help patients and their families process their experiences related to navigating the health care system (e.g., process conflicts with physicians, assist with advocacy for sundry wants and needs). At the macrosystem level, they can include families’ culture and religion into consideration while providing sensitive assessments and personalized treatment (e.g., facilitate conversations about possible cultural and/or religious considerations that may inform care processes).

This work is not easy within complex clinical situations wherein life and death issues are commonplace. It is family therapists’ responsibility to create space for and encourage all professionals to work together to facilitate systemic thinking. The time is now; we need to synchronously advance research and clinical efforts into this relatively uncharted arena of care. As we do, it is important to explore the organizational contexts of ERs so that we can develop and provide systems-informed interventions to—and with—patients, families, and providers synchronously. This will allow researchers and clinicians to extend attention beyond the traditional (narrow) definition of ER and MedFT services.

Conclusion

Mental health services provided in ERs—if any—generally lack a systemic orientation. Patients and families receive support individually and/or one member-at-a-time. Despite ongoing advancements in health care to integrate systems-informed behavioral health providers into biomedical contexts, a consistent paucity exists for doing this in emergency medicine. There are clinical, operational, and financial barriers to navigate. MedFTs and health psychologists, for example, are often systematically (via hiring policies) excluded from these teams. And, while mental health is generally covered under the purview of social work and/or nursing providers, care is generally advanced in a manner set up for relatively narrow presentations like assessing for suicidality and/or triage and referral to other care sites and hospital departments (Kassekert & Mendenhall, 2018). Moving forward, we must work past (or through) these interdisciplinary tensions and limited care scopes en route to better care. Our patients, families, providers, and care systems all stand to benefit.

Aalaa Alshareef, MS, is a doctoral student in the Couple and Family Therapy Program at the University of Minnesota’s Department of Family Social Science. She holds a Master of Science in Marriage and Family Therapy, and serves as a faculty member in a large psychology department in Saudi Arabia.

Tai J. Mendenhall, PhD, LMFT, is a Medical Family Therapist and Associate Professor in the Couple and Family Therapy Program at the University of Minnesota’s Department of Family Social Science. He is an adjunct professor and clinician in the UMN’s Department of Family Medicine & Community Health, an Associate Director of the UMN’s Citizen Professional Center, and the Director of the UMN’s Medical Reserve Corps’ Mental Health Disaster-Response Teams. He works actively in the conduct of integrated behavioral health care and community-based participatory research (CBPR) focused on a variety of public health issues. 

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Tai J. Mendenhall, PhD, LMFT, is a Medical Family Therapist and Associate Professor in the Couple and Family Therapy Program at the University of Minnesota’s Department of Family Social Science. He is an adjunct professor and clinician in the UMN’s Department of Family Medicine & Community Health, an Associate Director of the UMN’s Citizen Professional Center, and the Director of the UMN’s Medical Reserve Corps’ Mental Health Disaster-Response Teams. He works actively in the conduct of integrated behavioral health care and community-based participatory research (CBPR) focused on a variety of public health issues.