The Future of Emergency Psychiatry
Jon S. Berlin
Avrim B. Fishkind
Rachel Glick
Scott Zeller
One touchstone for the future adequacy of these ser-vices is whether we could honestly say that we would use them ourselves.
–Concluding sentence of the 1995 British text Emergency Mental Health Services in the Community (1)
Twelve years later and a continent away, the issue of adequacy looms as large as ever. As we have discussed, the configuration of the psychiatric emergency service (PES) derives considerably from its function as the safety net for an inconsistent, inefficient, and inequitable national mental health care system. But our emergency mental health services have problems of their own, and our first hope for the future of our discipline is a heightened awareness that, to a great extent, the future is what its practitioners make of it.
Berwick recently wrote, “The average Ameri-can does not reliably receive care of high quality” (2). The various parts of the health care system are interdependent, and emergency care cannot be completely fixed in isolation. But emergency care clinicians and service leaders cannot wait for reform on a national scale. We should look at our own services. The Institute of Medicine and other advocates of change point out the need for care to be patient centered, systems minded, and knowledge based (2,3).
QUESTIONS FOR THE FUTURE
Practitioners of emergency psychiatry have many questions to answer in the future. We must grapple with issues of patient-centered care, the role of the PES within the overall health delivery system, evidence-based practice and the fund of knowledge related to psychiatric emergency care, future research, and the integration of technology into psychiatric practice.
Patient-Centered Questions
In this text we have included chapters on administration, training, interviewing, and noncoercion and have tried to emphasize the importance of engaging the patient in his or her care. But do we practice what we preach? Do we and our colleagues engage with patients on a very real, human level from the moment of the first encounter? Do we support, train, and certify our PES security staff, clerical staff, and other persons who meet patients at the front door? Do we actively involve patients and their families in the development of their treatment plans, and address advanced directives? If patients are temporarily out of control, do we help them regain control over themselves? When patients are waiting long periods of time between clinician contacts, do we explain what we are doing, why we are doing it, and how long it will take? Or do we take over control without explanation, never to give it back? Do service leaders train themselves and their staff to recognize and understand countertransference, to keep from acting out unproductively in provocative situations? Do we strike the best possible balance between a patient’s right to safety and personal dignity? Are peer support specialists used as widely as they should be to sensitize clinicians to what it feels like to be a patient? Has every practitioner thought through what it would be like to receive coercive treatment or how the sound of staff members laughing might be misinterpreted? Do service leaders effectively advocate for the resources required to handle surge volumes that outstretch service capacity and cause care to suffer?
Systems-Minded Questions

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