The crisis response system for mania, psychosis and suicidality needs to change. It’s currently dangerous, and often fails at the job of a) keeping people alive through a crisis and b) helping them metabolize the experience to become more resilient to stressors in the future.
The psychiatric crisis system is the set of interconnected emergency services, medical, and social work systems that get involved when you have a psychiatric crisis in a country with Western medical systems. This includes the paramedics and their ambulance who attend a 911 call; the triage nurses in a standard ER who interact with psych patients; the laws that govern when a psychiatrist can recommend that someone be held for psychiatric treatment against their will. There are many interlocking parts, and as a patient or loved one of a patient it can be extremely overwhelming to interact with.
It’s dangerous because it relies on a system for organizing workers, time, space and tools as resources that was optimized to diagnose and respond to physical, medical problems in a resource-efficient way. It can respond extremely quickly, which is why we still use it, often as a last resort. This structure is easy for motivated patients to hack, alienates patients already suffering from extreme alienation, demotivates clinicians, and often actively hinders patients’ recovery. It is expensive to run and has a terrible reputation amongst those who may need to use it or have used it, which means many patients avoiding seeking care even when they need help. And, it has a monopoly–there are no commonly available alternatives for someone who needs help within minutes or hours, in part because legal constraints prohibit the development of alternative systems that have the same capacities.
I want change to happen in at least three broad directions:
Allow the therapeutic alliance to develop
The quality of the therapeutic alliance is the defining determinant of the success of all kinds of psychological treatments, and the fragmentation of treatment relationships in current crisis response systems inhibits the process of building this alliance completely. In simple terms, you need to build trust with the specific people helping you in order to heal, and the structural organization of these services currently makes that extremely difficult.
I want the psychiatric crisis system to be disaggregated from the medical emergency system and to operate on a location-agnostic principle of psychological continuity–that is, rather than an emergency warranting a trip to a primary place (the ER) where the triage system ensures you will get a response to your problem once someone there is ready to respond to you, the crisis is responded to by a primary responder (who likely has a team) and that person will be available for you throughout the crisis up to and including spending time with you in any second place you need to go to–like a ward.
In the long term this would involve the replacement of isolation-inducing locked wards with non-medical homelike second environments that can be more responsive to patients’ changing needs for restraint versus freedom than existing hospital wards.
Implementing psychological continuity in the shorter term involves refactoring the professional roles involved in crisis response, redesigning administrative, credentialing and reporting practices that inhibit single-handling of patients, and implementing new resource-management protocols that allow the pool of crisis responders to be effectively deployed to serve a given population in a continuous rather than fragmented way.
- Measure the degree of psychological continuity in current major crisis systems
- Document the implementation of existing high-psychological continuity crisis response systems as case studies for other systems to implement
- Propose alternative scheduling allocation mechanisms that prioritize psychological continuity
Policy and advocacy goals:
- Formulate a proposal to develop continual contact between a mobile responder team and their patient
Help crisis response become more compassionate
I also want to improve the level of compassion that most patients experience from a crisis responder or team. Psychiatric crises involve an increased risk of suicide, homicide, injury and accident, and so a lot of existing crisis response processes involve powerful strategies to minimize these risks, particularly when responders are physically at risk or professionally liable for incidents that may happen.
However, effective de-escalation and long-term integration of a crisis experience requires a patient being able to accept what happened and why, and this is much easier when the patient feels respected, dignified, and cared about by those around them, including the crisis responder.
Increasing compassion involves changing multiple aspects of crisis care, including pay and roster factors that lead to burnout, antagonistic relationships between workers and management, time pressures caused by billing and scheduling constraints, professional taboos around warmth, spirituality, and informality, and the social status of psychiatric crisis responders in the clinician community.
- Learn what stops crisis responders from being paid more, and what causes labour shortages
- Document the major catalysts of crisis responder burnout
- Document the existing cultural norms of crisis responders (mobile teams, ERs and inpatient) around warmth, spirituality and informality
- Investigate the major contributors to time pressure amongst crisis responders
- Build a community of practice for crisis responders around compassion
- Identify crisis response leaders who are already excellent at integrating risk-assessment with compassionate response and build relationships with them
Policy and advocacy goals:
- Reduce the time pressure on crisis responders from billing system design issues
- Create a list of administrative constraints that make compassionate responses unnecessarily difficult for crisis responders and advocate for their removal
Introduce soothing, socializing and sensemaking, not just drugs and restraint
Lastly, I want the treatment paradigm to extend to include multiple ways of making sense of a crisis, reducing the risks associated with it, and accounting for a patient’s social and physical environment.
Currently the predominant treatment paradigm in crisis psychiatry is neurophysiological, and treating clinicians respond to patient mania, psychosis or suicidality immediately and aggressively with mood stabilizers, anti-anxiolytics, and antipsychotics, alongside seclusion and restraint, and have limited other treatment possibilities available to them. These drugs often have strong side effects like weight gain, brain fog and tardive dyskinesia that patients complain about to no avail, and can inhibit their development of strategies for coping with the crisis experiences, or inhibit important other experiences like creativity or joy. The dominance of pharmacological responses also contributes to social narratives about patients being ‘broken’ and reduces their agency in relation to their stressors and their treating clinicians.
Expanding the treatment paradigm to include soothing, socialising and sensemaking would reduce the side effect burden of drugs on patients, but also create the conditions for patients to develop their own resilience. To do this requires reducing the professional constraints that force psychiatrists to conform to maximum medication treatment plans, developing capabilities for soothing, socialising and sensemaking within crisis response teams and their relevant physical environments, and removing administrative, legal and payer-driven barriers to teams developing these capabilities.
- Document the legal and licensing restrictions that limit psychiatrists from using minimal medication treatment strategies
- Document the rules, restrictions and physical constraints that limit soothing, socializing and sensemaking in conventional psych wards, as well as in existing alternatives
- Investigate the characteristics of psych wards and alternative environments that patients describe as facilitating soothing, socializing and sensemaking
- Build a community of inpatient and emergency psychiatrists who want to develop minimal medication treatment strategies
Policy and advocacy goals:
- Advocate for changes in the licensing requirements for psychiatrists to allow them to pursue minimal medication treatment strategies.
- Advocate for changes in the legal architectural requirements for psychiatric facilities to allow more soothing, socializing and sensemaking activities
This project was started with the stated goal of making Western psychiatric crisis care more humane and better at serving its goal of supporting all people through a crisis situation and into an effective healing process. All of these words, however, can be understood differently by different people, and the underlying, felt experience of the people involved the system, including patients, clinicians, administrators and managers, is more important than the words used to describe them. It’s my hope that this explanation will develop further and become clearer and more resonant to more people as I and others learn more and develop more articulate language to describe the future we are aiming at.
Some open questions
Why are there no acute mania crisis response programs? Mania has unique risks and characteristics, and there are acute suicide, psychosis and overdose response programs in various jurisdictions around the world, but not a single program I can find to specifically respond to mania. Why?
Why are people who work on crisis response teams, like social workers, peer workers, and therapists, paid so little, given such demanding schedules, required to have such expensive and time-consuming credentials, and seemingly in shortage in many jurisdictions? What’s going on with this labor market?
Why do so many flourishing experimental psychiatric environments fail once their founder leaves? Why do so few such projects succeed in expanding to the mainstream system?
How can the informal, egalitarian, empowering values of the peer community be protected as peer work becomes increasingly credentialed and integrated into large mainstream systems like hospitals?
How can we increase the practical safety of crisis responders going into unfamiliar environments, and reduce their need to call on police for protection?