Chapters on the use of medications in a crisis usually start with a discussion about when medication is needed, what medication to use, and how it can be used to decrease agitation (2). That is, the discussion typically starts from the professional view of both the problem and the range of possible solutions. The problem from the clinician’s point of view is the patient’s agitation and irrationality, and medication is a readily available solution to this problem. Engaging crisis patients regarding issues of medication requires that we start with the process of engagement rather than starting with the medication. Engagement requires that we start with the patient’s own experience. Solutions, as much as possible, should relate to that experience. Engagement is a two-sided process that requires collaboration between the patient and the clinician. Engagement does not begin with the expectation that the patient will understand the clinician’s point of view; it begins with the clinician’s willingness to understand the patient’s point of view (3).

A crisis is often a very difficult time during which to develop a collaborative relationship. Time is short, there is pressure to act rapidly, anxiety is high, and the patient and clinicians typically have no previous relationship. Crisis clinicians are concerned with ensuring the physical safety of both patients and staff. Crisis intervention and collaboration often seem to be in conflict with each other, and it is often difficult for crisis staff to know how to do both at the same time. Within this context, it is easy to see medication as the solution to reestablish control, and to see engagement as a luxury that can be put off until after the immediate crisis has stabilized. Medication is available as the trump card that clinicians can use as necessary if the relationship is not going well. Both clinicians and
patients are aware that “medicating the patient” is always an available option. Both clinicians and patients are aware that in the final analysis, clinicians have the power to exert their will and their solutions on patients, and this asymmetry of power is an inherent part of the relationship between the crisis staff and the crisis patient.

The term crisis comes from the Greek krisis (literally, “decision”), from krinein, “to decide.” Crisis, by definition, is chaotic, unstable, and requires rapid decision making. It is inherently unpredictable. Needs, capacities, and goals are constantly changing. Collaboration comes from the Latin com (“with”) plus laborare (“to labor”) and means to work jointly with others, especially in an intellectual endeavor. A decision made in collaboration between patient and clinician working together may, initially at least, take more time than a decision made by just the clinician.

It is sometimes felt that the time and trust needed for effective collaboration are not readily compatible with the need to impose a structure to rapidly organize and resolve chaos. Actually, collaboration can help crisis resolution. The conflict between crisis and collaboration is more often an issue of perception than of necessity. In most situations it is possible to carve out the time and structure for at least some level of collaboration to take place. In rare cases, this is not possible, and the immediate need to ensure safety must take precedence over other issues. There is a dynamic tension among the need for safety, the time constraints of a crisis service, the need to impose order and structure, and the need to engage the patient and begin the process of collaboration. Engagement is critically important, but so too is establishing safety and decreasing the sense of chaos. The process of balancing these issues lies at the heart of crisis intervention. Too often, collaboration and engagement are considered less important in the immediacy of the crisis situation.

Crisis intervention has three primary goals. The first goal must be to contain the risk of immediate harm (4). It is always possible to medicate a patient into submission, and in some cases rapid pharmacologic control may be required. More often, risk containment requires working with the patient to help him or her calm down. Although medication can be helpful, having someone take you seriously and listen to your version of your story can be extremely validating, as can the experience of having someone really on your side. Patients are often agitated because they are afraid, confused, overwhelmed, and alone. Patients will very often calm down if they feel some sense of hope and a sense that they are not alone. This is not accomplished by talking at the patient; it is accomplished by listening to the patient. Patients often feel very out of control, and usually would like to be more in control. Medication can be something that is “done to” the patient, or a tool that the patient can use to help reestablish control over himself or herself. When medication is imposed, it can increase the patient’s sense that he or she is out of control. Even when medication needs to be imposed over the patient’s objection, it can be framed as something that will help the patient get back in control. Collaboration can be encouraged even when some part of the treatment may be involuntary.

It is also important to manage the postcrisis risk. It is not possible to eliminate or predict all risk. Not everyone who is angry or threatening or feeling somewhat suicidal can be or should be hospitalized. Although hospitalization may decrease the immediate risk, it can exacerbate long-term risk in some situations. Risk assessment requires that the patient be willing to share his or her thinking, which requires some degree of trust and collaboration. How the initial phase of crisis intervention is handled can significantly increase the quality of the postcrisis risk assessment.

The second goal is to help resolve the crisis. This typically involves helping to replace the chaos and loss of control of the crisis situation with a sense of order and direction. Crisis resolution requires understanding the cause of the crisis, putting the crisis into the larger context of the patient’s life, and coming up with a plan for how the patient and staff can resolve the crisis. Crisis resolution is much more than just sedating or placating the patient. It is helping the person reestablish control over his or her own behavior. This is much more likely when the person in crisis can partner with the crisis clinician. It is more difficult if the patient feels he or she must reestablish this control alone, without any outside help.
Help in this sense requires collaboration. Collaboration requires working together toward some common goals. It is difficult to imagine working together if there are no goals with at least areas of overlap.

The third goal is to use the crisis situation to support postcrisis recovery. The goal is not only to resolve the immediate situation, but also to help avoid similar crisis events in the future. Even more may be possible. By definition, a crisis period is a period of flux and change that is both a time of opportunity as well as a time of risk. The period of crisis can often lead to permanent change. The goal is to use the crisis intervention to make this change positive rather than negative. Crisis staff and emergency department staff should understand that their intervention at the moment of crisis can make the patient’s ongoing quality of life better or worse. Attending to the immediate crisis alone is not enough. The long-term consequences of the crisis treatment should always be considered.

Collaboration is required for all three of these goals. Trust and communication are required to partner with a person. Collaboration is required to conduct a risk assessment. And collaboration is critical to increase the likelihood that the crisis period will lead to permanent improvement. Crisis resolution is not something that can be “done to” the patient; it is a process that must be done with the patient. Medication can help a person calm down, communicate more clearly, and feel better. Medication can help a person enter into a collaborative relationship with the clinician. However, medication can also interfere with this collaboration.

Engaging patients regarding medication requires engaging patients in the entire process of crisis resolution. A collaborative approach to crisis resolution has four parts: