A Conversation About… Emergency Psychiatry – Part 1

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Host (00:01):

Hi there. Welcome to Mental Health Professionals Network podcast series. MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Professor Mark Creamer (00:18):

Hello and welcome to this episode of MPHN Presents A Conversation About, my name’s Mark, Mark Creamer. I’m a clinical psychologist and professorial fellow in the Department of Psychiatry at the University of Melbourne. My specialty is the mental health effects of trauma, but I’m also really interested in emergency mental health, and I worked for many years in public sector psychiatry. So, it gives me great pleasure to host this three-episode series in which we’re gonna explore several aspects of emergency mental health. This is the first episode in the series, and I’m delighted to be joined by Dr. Song Chan. Song is a consultation-liaison psychiatrist working at Middlemore Hospital in New Zealand in Auckland. He’s got a particular interest in emergency psychiatry, and he has recently reviewed models of care for individuals presenting to emergency departments with acute behavioural disturbance. So, he’s clearly the ideal person to be chatting to me today about tips, strategies, and methods to de-escalate a mental health crisis. Hi Song. Thanks very much for joining us.

Dr. Song Chan (01:29):

Hi Mark. Thanks for the invitation from across the Tasman.

Professor Mark Creamer (01:32):

Yes, indeed. Indeed. We’re gonna be talking all of this episode about crises and so on. So, let’s start off with something slightly lighter. I always think it’s really important for our own mental health that we have activities outside of work that engage us. Can I just ask you quickly what you do when you’re not on the front line of psychiatry?

Dr. Song Chan (01:49):

When I’m not on the front line of psychiatry, I am either cooking up a storm in the kitchen, pretending that I’m a foodie, or more recently I’ve got into gardening. So, I like to view myself as a somewhat capable amateur gardener. Though the New Zealand floods this year may have put a little bit of ruin to my garden, but nevertheless, it’s salvageable and things are looking good going into winter.

Professor Mark Creamer (02:15):

Sounds great. Sounds great. And I always think I’m not a gardener, but I always do think that gardening must be a very good thing for your mental health.

Dr. Song Chan (02:21):

Most of the time.

Professor Mark Creamer (02:22):

Most of the time I’m sure it has its frustrations. Today we are going to be talking about how to manage a crisis occurring in a mental health setting. And I guess for most of us, and I absolutely include myself in this, these are challenging situations. They’re not something that we look forward to. And so, I’m fascinated to know a little bit about your experience in the area and I guess particularly how and why you became so interested in this very, very difficult area.

Dr. Song Chan (02:51):

First of all, I guess I fell into this area because I did a lot of my training in it as a registrar, I was always very interested in systems and sort of how acute systems work. In particular, for the bulk of my training in Auckland, I’ve worked in South Auckland, which is a very socioeconomically deprived area with a large proportion of the people walking through the front doors of the hospital being Māori or Pacifica. For our Australian listeners, the Māori people are our indigenous people of New Zealand and Māori and Pacifica, by and large are overrepresented in adverse health outcomes and particularly in the mental health setting, they are significantly overrepresented. In fact, probably over 50% of our presentations at Middlemore Hospital for mental health problems are people of Māori or Pacifica descent, which is quite surprising given that proportionally it’s much, they make up a lower proportion of the population in Auckland.

(04:04):

I’m particularly interested in this area because we don’t do a good job. I think clinicians always have goodness in their hearts. We always want to do the best for the people who come in through the front door that we work with. But due to a combination of factors, including how the system is structured, the business of the environment, and perhaps our own biases being sort of in a very stretched and somewhat exhausted and burnt-out workforce, we don’t always deliver the best care that we’re capable of. And this is the passion ultimately that drives me to really improve things at the front end of the hospital.

Professor Mark Creamer (04:44):

Yeah, absolutely. Absolutely. And it sounds like you are working in a setting where you are getting a disproportionately high number of these kinds of crises really. I suppose I would like to make clear right at the outset though, that mental health crises don’t only occur in emergency departments or in acute psychiatry settings. And in fact, our outreach teams, our crisis teams, and indeed in our own consulting rooms, we can also confront mental health crises. I guess.

Dr. Song Chan (05:09):

That’s very much true and you’re very right. It extends beyond the front doors of the emergency department. Crises are everywhere. I encounter crises when I work for the crisis team after hours. I encounter crises while on medical wards. In fact, you can even have crises at schools and offices that there’s no limit to the number of places where a crisis can spontaneously appear.

Professor Mark Creamer (05:33):

Absolutely. And I’ve no doubt that what you are going to suggest for us is gonna apply across settings. So that’s great, we’ll keep that in the back of our mind. But I guess when we talk about mental health crises, can we just talk a little bit about what that means? What kind of situations we might be considering that we would label as a crisis?

Dr. Song Chan (05:51):

I think fundamentally it can be a little bit difficult to give a clear definition of what situation might consist of a crisis. I prefer conceptually to think about it as a spontaneous period of distress that really affects a person’s mental health and mental wellbeing at any point in time. And I think that’s really important to capture that. It might not necessarily be related to mental illness if we are sort of very much sticking to a medical viewpoint or a diagnostic viewpoint of things where we talk about mental illness. But it can actually be situational, it can be social. Anything can cause a crisis in a mental health setting.

Professor Mark Creamer (06:31):

I think it’s a very important point, isn’t it? And I guess I was at risk of jumping straight to the idea of a crisis as perhaps a threat of violence, threat of violence to self or others. And actually, I should just tangentially say here that our next episode is gonna be devoted to suicide. So, we might mention it today, but we’ve got a whole episode next time. But it isn’t just threats of violence or, or or necessarily bizarre kind of acting out behaviour.

Dr. Song Chan (06:55):

That’s very much true, Mark. It’s not just that bizarre behaviour. Sometimes it might also be a threat to self. And I think later on you’ve got a session about managing suicide threats and suicide risk and it’s not just threat to others. A crisis has many shapes and many forms, but it’s a change from the norm and someone is distressed, and it can be reflected outwards or inwards depending on the situation.

Professor Mark Creamer (07:23):

Very quickly, do you think we need to consider the role of substance use, substance abuse in the generation of crisis?

Dr. Song Chan (07:29):

I think we always need to keep that in the back of our minds, but one of the things we also need to be cognizant of, I think as mental health practitioners is not to exclusively blame the role of substances for someone a ending up in a crisis. Often, we work with individuals where substance use is a product of a crisis, and it rather adds fuel to fire rather than being the underlying cause.

Professor Mark Creamer (07:58):

Yeah, absolutely. Absolutely. Okay, well perhaps that kind of leads onto what I was thinking of next and that is, I guess before we get to the actual crisis, prevention is always better than cure. Presumably, if we can intervene early to stop the situation escalating into a crisis, that’s a good thing. I, I just, I wonder if there are any sort of warning signs that things might be about to spiral out?

Dr. Song Chan (08:21):

I think it very much is situation and setting dependent, but a lot of the time what you might observe in people beginning to escalate is that you might notice subtle changes in terms of body language. The body language might become a little bit more forward or a little bit more aggressive if you want to call it as such a bit more going into someone’s personal space. Their voice might escalate, they might get a bit louder, shouting might begin. These are signs that people are potentially starting to become more distressed. The crisis might be evolving, and the crisis might be escalating. So, we should always be aware of these signs, these changes I guess, of how we outwardly express ourselves when we’re with anyone who may be experiencing a mental health crisis.

Professor Mark Creamer (09:12):

Hmm, and I guess actually tho those kinds of signs are things that loved ones or people who know the patient or the person very well, they’re more likely to recognise perhaps than someone who like us who may not be familiar with the person at all.

Dr. Song Chan (09:25):

I think that’s very true. Mark and I often tell Whānau that I work with, Whānau being family and Māori, that Whānau are the experts. They are the ones who know their loved ones the best. They are the ones that can give us guidance and advice and we as clinicians really should tap into their knowledge and work collaboratively with family where possible because family are often critical in terms of a crisis getting outta control or a crisis getting in control.

Professor Mark Creamer (09:56):

Yeah, and that’s something of course it would apply very much beyond the Māori culture into pretty well most cultures really. Family’s important, isn’t it? Yeah. Well, let’s assume that the situation has escalated then, and we find ourselves confronted by a mental health crisis. Can we talk for a while what, what your advice would be about how best we might manage this situation?

Dr. Song Chan (10:20):

I think we can always think about the management of crisis in a bit of a stepwise fashion. It’s about escalating our response at each checkpoint to make sure that we’re doing what we can to dampen the response or to dampen the crisis or get things in control as much as possible. As a starting point before we go into any of these steps, the most critical thing I think as a mental health clinician is to think about the person who’s in front of you. Why are they possibly in a crisis? Remember that if you don’t understand why someone is experiencing a crisis or don’t even have any hints, it can actually be quite difficult to contain a crisis. Once it gets outta control, we need to figure out what the person wants or what they need at that point in time.

Professor Mark Creamer (11:10):

Hmm. I think actually, just to interrupt there, I think if we’re gonna take one take home message, I’m already deciding that’s gonna be one of them that we, we can’t manage the crisis unless we know why the person is in crisis.

Dr. Song Chan (11:20):

Yeah, that’s very true. Mark. I think it’s difficult to do effective crisis response or crisis management if you don’t know what the underlying precipitant for the crisis actually is. Let’s go back to sort of our stepwise thing before we even get round to engaging the person in crisis, no matter the setting, we first need to take a bit of a step back, take a breath, remember that if you rush in and think impulsively, act impulsively, sometimes it can add fuel to fire. So, take a step back, have a brief think and think about the environment. I talk about the environment because we need to think about what sort of resources we’re working with and what the current situation is like. If I’m to give a bit of an example, if someone’s been brought into the emergency department, like last week, very distressed, unfortunately got brought in with police officers, but they were starting to escalate in terms of the agitation because they were really frustrated, and they weren’t treated with respect.

(12:28):

Thinking about the environment, I needed to consider the fact that it was an emergency department. There were lots of objects around and also that the environment itself is loud, there’s lights everywhere. There’s 4, 5, 6 people around this person who’s experiencing a bit of distress. If we put ourselves in the individual shoes, it’s an immensely overstimulating and distressing environment. So, before we even get round to starting to deescalate, we need to think about is the environment that we’re in going to make things worse. So particularly the two environments in my line of work that will escalate crises if we don’t think about them actively are the emergency room and police stations. Because police stations are often associated with, I guess actions by police officers. It may be associated with previous trauma for people who may have had adverse interaction or negative interactions with police historically. But also, for minority groups who have had bad experiences with police throughout a large portion of their life. A police station can be highly triggering and actually quite very traumatic for them, which adds fuel to the fire.

Professor Mark Creamer (13:51):

Yeah, quite And of course it, it’s a pity because the first people that often are thought of in the case of mental health crisis are gonna be the police will get the police in, which is you say actually sometimes is of course essential, but sometimes may serve to exacerbate things.

Dr. Song Chan (14:04):

Yeah, and that’s very true. So, it’s important to stock and take note of what in the environment can be adjusted. If you are in an office and someone is starting to escalate, if they are already at the point where the highly aroused, you need to think about your safety, how much can you mitigate the situation? Because if someone’s going to grab a chair because they’re very distressed, you might need to call for help. You might need to take a step back before getting control of the situation. So, this is the environment stuff I talk about initially. But once we get past the environment part, the first thing all of us need to do is introduce ourselves. Who are we? What is our role? We can’t just sort of invade into someone’s personal space without actually telling them who they are. For people who have experienced crises previously and may have been on the receiving end of treatment against their will, it can be exceptionally threatening if you are coming up to them immediately telling them what to do and not actually explaining what the purpose is, who you are and what’s going to happen. So that’s the first tip. First step is really tell someone who you are, “Hi, my name is Song, I’m one of the psychiatrists here. Let’s have a bit of a talk about what’s going on because it sounds like you are really distressed at the moment. How can I help?” That is the first step I think in terms of managing these situations. Be calm, be non-confrontational, have a steady but not loud and aggressive voice.

Professor Mark Creamer (15:48):

And you’re already starting there to develop a relationship with this person I guess by introducing yourself.

Dr. Song Chan (15:55):

Very much so. Often, we as clinicians, particularly in mental health, become quite focused about wanting to do an assessment for lack of a better term, to gather the information. One thing I want all you listeners to think a little bit about today is doing an assessment is not merely asking a predetermined set of questions to get what you want. That’s your agenda. What is the person’s agenda in front of you? They often want to be heard. They often are presenting in a time of crisis and distress. They often want some human interaction and understanding, that’s their agenda. So, by introducing yourselves and starting some lighthearted talk just to set the scene a little bit and to provide and project some calm, it actually gets you some information. You’ll be able to understand why they’re there. They might tell you a little bit about what’s going on without you actually having to go through your predetermined checklist. And we can call it that, that we’re often quite tunnel visioned on when we ourselves are trying to manage a crisis, we regress back to that cuz it’s comforting.

Professor Mark Creamer (17:06):

Exactly. But this way it has the potential to be more of a conversation, I guess more of a, an interaction and helps the person to feel more reassured than being battered with questions.

Dr. Song Chan (17:17):

Very much so after we introduce ourselves and we start up a little bit of that conversation, if they’re amenable, then the next step I often find useful is asking the person, should we go somewhere a bit more quiet to talk? Because if we’re not in a suitable place for talking, it can often be really hard for you to gain control of a situation which has the potential to spiral out of control. For example, if I’m seeing someone in a police cell, it can often trigger lot of memories, particularly traumatic memories for people who have had bad experiences with the police. So, bringing them to an interview room in a police station away from the confines of the cell might actually be a a bit less stimulating for the person, and it allows you the chance to engage them in conversation in a bit more of a relaxed environment.

(18:11):

In an office or clinic setting, if they are distressed in the reception waiting area, bring them into a side room, bring them into an office, give them a bit of space just so they know that they have the time of day, they have your attention and that you are focused on them as opposed to everything else that’s going on in the environment around the two of you. Then the next step is about listening. Often clinicians, when we deal with crises, we might forget to listen and that’s normal. We forget to listen because we’re so focused on the situation and what’s in front of us. We want to assert control. But often what happens then is we end up in this tug of war where we might be perceived as not listening to the person trying to tell us their story, trying to tell us what’s brought them here, trying to tell us what’s precipitated this crisis to begin with.

(19:09):

So, we should listen, we reflect, think particularly about active listening. Are we listening to everything that’s coming out, understanding it, acknowledging it, and we are possible when we are listening and conveying messages back. Avoid ultimatum. Ultimatums are one of those things that in a situation of crisis can cause things to absolutely surge out of control. If you are dealing with an individual who is already threatened, they may escalate things significantly quicker. If they feel backed into a corner, it becomes a fight or flight type response. Human nature. And the final step really that we’re gonna get to is remembering that people often have needs people come to the emergency department in a time of distress. Often even in a clinic, in a GP office setting. Or if you’re seeing someone say at a homeless shelter, they might not have food, they might be thirsty, they might need a drink and so small gestures like that when someone is acutely distressed or escalating in a crisis can actually do great wonders to dampen things down. So just to recap, really the four steps we’ve talked a little bit about is introducing yourselves, looking at the environment, is it suitable, bringing them into a quiet space and then actively listening to someone and thinking of what needs they might have?

Professor Mark Creamer (20:39):

Yeah, tremendous, tremendous. That makes so much sense. I was actually making notes myself and hopefully our listeners were also making notes and underpinning all that is our goal of trying to understand what’s driving the behaviour and and and so on. I guess we have to be realistic though that even if we do go through all those stages perfectly, there are going to be some crises that we are not able to deescalate and there, I guess perhaps we do sometimes need to call for more restraint. We sometimes do need to call for the police or whoever.

Dr. Song Chan (21:09):

That’s very true. It’s unfortunate when crises reach that level, but you’re right in that it does happen on a day-to-day basis. So we can try intervene as much as we can, but when crises do run the risk, I guess of getting outta control, similar to what you’ve just mentioned, it’s important with your approach to really keep in mind that what you do, the person can remember for long periods of time. It can cause a lot of trauma and for people who’ve been in these situations on previous occasions, potentially we can cause them to relive trauma, which may lead to worse outcomes in terms of mental health further down the line.

Professor Mark Creamer (21:57):

Hmm. The the other point I was wondering about was, I guess we perhaps wouldn’t see this crisis in isolation, but rather in the context of their broader life and perhaps mental health management and I guess we’d be trying to involve other members of their treatment team, perhaps the GP and, and as you said perhaps the family and so on around the person through, through this crisis.

Dr. Song Chan (22:17):

Definitely. And it’s really important to do so because what we find useful most of the time is tapping into as many support structures as possible. I think of it as scaffolding, a bit like building a house to really lay the foundations well to support the person going through a crisis. We use the housing analogy. A crisis is a bit like a big gust of wind coming, which threatens to blow things down. So, a strong foundation in terms of their treating team, their family services, all of those are really important to keep the house upright, particularly in a time of crisis like this.

Professor Mark Creamer (22:59):

That’s a lovely analogy. Yeah, yeah, absolutely. Okay, so the bottom line is that there’s a lot that we can do, and I love your four points. You know, I like nice clear kind of guidelines like that. So, your four points, these are skills that we can learn and perhaps should be incorporated into our training programmes in psychiatry and indeed other mental health areas.

Dr. Song Chan (23:20):

I hundred percent agree with you. They are fundamental skills for anyone practising in health, not just mental health, but in health in general. I think crises occur everywhere. As I said at the very beginning across the hospital and the GP clinic on the street. These are skills that I think all of us as clinicians should be developing and working hard to refine. I think all of us will have our own styles and it’s okay to have a different style because that’s who we are as individuals, but it’s to remember some of the underlying concepts in terms of managing these situations.

Professor Mark Creamer (24:00):

And particularly important for those of us who don’t encounter these situations very often we don’t have much opportunity to practise, but at least having that context, that structure in our head is really important. You kind of have sort of answered this already, but I do wanna mention it again briefly and that is, as I started off by saying that these situations can be quite frightening for clinicians quite confronting, quite distressing and so on. And I’m wondering about whether you’ve got any advice about how we could be managing, should be managing our own feelings in these situations. I’ll just pick up on what you said something about stepping back and kind of taking a deep breath and so on. It was obviously very important, but have you got any advice for us about how to manage our own fear, our own arousal?

Dr. Song Chan (24:42):

I think the first piece of advice I’m going to give is it’s okay to be scared. These situations are scary situations when we find ourselves in them. I think it’s important to acknowledge that if you are experiencing such a situation, it is likely the person working alongside you, the team working with you are all likely going to be feeling similar things. These situations are never easy to manage. So, as a psychiatrist I would often recommend a lot of my clinicians who work in the acute space to think about peer supervision. Peer supervision is often quite helpful when you need to discuss a lot about a situation, particularly about your emotional responses to situations in a safe and contained space. One of the things that the health system particularly doesn’t do well in, and this is a bit of an aside Mark, one of the things we don’t do well is in the health system is actually taking a step back and thinking about why we respond to situations in a particular fashion because we’re always on the go and this leads to us stigmatising certain individuals that might lead to us stigmatising certain groups of individuals because of previous negative responses.

(26:00):

And we do it in a very defensive fashion because we don’t want to be on the receiving end, I guess, of a particularly difficult situation that we have encountered previously. So going back to it, supervision’s important with peers but also after a situation where you might have multiple people involved in managing a crisis debriefing is very useful. It’s useful to talk about people’s emotions at that point in time. What happened, what did they do well? What could we improve on next time? We as humans often tend to err on the side of the negative when we talk about things that are done bad. But it’s also important for us in any debrief to talk about what we did well. It’s important to reinforce the positive things that we’ve done in a situation as well.

Professor Mark Creamer (26:54):

I agree and entirely in that we are looking at it as a kind of, we might call it an operational debrief about what went well, what didn’t and so on. But that process I think is often very important for our psychological wellbeing. It adds an element of closure, doesn’t it, it helps us to kind of move on.

Dr. Song Chan (27:07):

Yeah, it, it’s definitely closure but taking it beyond that, I think it’s also understanding. So, it provides us a bit of context if we encounter a similar situation again to understand why we might have certain emotional reactions.

Professor Mark Creamer (27:23):

Yeah, I agree. And just to pick up on your earlier point about supervision and sort of reflective practise kind of ideas, the last episode in this series is about looking after yourself and I’m sure that we will be coming back to that topic cuz it’s very, very important. Can I just quickly throw this one at you? I guess that this is a very difficult area in which to be setting up rigorously controlled scientific research and so on, but I just wonder if we do have an empirical evidence base around crises, around psychiatric crises and so on.

Dr. Song Chan (27:52):

Look, I think it is a very, very difficult area. It’s hard in a traditional medical sense to create trials that you could state are quite ethical. You can’t do randomised controlled trials to put people into intervention or non-intervention groups when people are in a crisis. But what we do have though across the world is an increasing number of interventions, increasing numbers of papers that talks about interventions in the acute space, particularly in terms of managing crisis. Now, obviously my area of expertise is in the emergency department. There are in increasing numbers of papers about brief interventions in the emergency department. I think it’s a promising area. We’ve got a long way to go, but I’m hopeful in the future that we’ll have a bit more guidance about what works. And I think it’s imperative that we get there because we are, I guess in a time and age where we are much more cognizant of our mental health and crises are unfortunately becoming somewhat more common as we have more stress in our day-to-day life.

Mark Creamer (29:03):

Absolutely. I mean, gosh, this is a whole podcast in itself actually, isn’t it? About whether they’re becoming more common and why, and as you say, more stress in our day-to-day life are perhaps a breakdown in some of the structures, societal structures that used to be protective anyway. Look, fascinating stuff, Song and unfortunately the clock is against us, but we’ve covered a huge amount of ground today and I have no doubt that it will be of great interest and value to our listeners. I hope that they enjoyed this conversation as much as I have, and I hope we have. So, thank you very much indeed for your time today, Song.

Dr. Song Chan (29:36):

Thank you for having me, Mark.

Professor Mark Creamer (29:38):

I do encourage everybody to listen to our next episode when we’ll be talking about tips and strategies to manage suicidal behaviour. So that will follow on very nicely from todays. If you want to learn more about Song or myself or if you want to access any resources, go to the landing page for this episode on the MHPN site. And there also you’ll find a link to a feedback survey. So, I really would encourage you, please to follow the link. Let us know how you found this episode, give us comments or suggestions about how MHPN can better meet your needs in the future. Thank you again to you Song. Thanks very much indeed and it’s goodbye from you,

Dr. Song Chan (30:17):

Goodbye from me across the Tasman!

Professor Mark Creamer (30:18):

And it’s also goodbye from me. Don’t forget to join us for our next conversation in this series when I’ll be chatting with Dr. Tad Tze about how best to manage suicidal behaviour. In the meantime, thank you all very much indeed for joining us today and for listening to the podcast. Bye for now.

Host (30:38):

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