Combining Recovery, Medical Models to Improve Emergency Psychiatry Outcomes

One of the liveliest debates in current psychiatry has been about the pros and cons of two general care rubrics — the recovery model and the more traditional medical model.

Roughly described the medical model puts more emphasis on evidence, symptoms, and treatment protocols, with an aim on achieving specific outcomes, whereas the recovery model prioritizes hope, personal empowerment, peer support, and coping strategies — seeing recovery as more of a journey than an end point.

There is certainly no reason that one model must be solely accepted over the other. No doubt, with all our patients having distinctly individual wants and needs, there are opportunities to adapt components from both philosophies in various patient encounters.

Perhaps embracing the best of both models can help lead the way to a middle-ground approach that better benefits urgent care patients.

Along those lines, here are some recent innovations in crisis care that show how one model’s viewpoint has been influential in affecting positive change, and a couple ways the two models may be able inform the other in the future.

Recovery Approach: Crisis Intervention Training for First Responders

When individuals are in a psychiatric crisis, they are often in a very vulnerable state, and in need of sensitivity, support, and understanding rather than force, coercion, or criminal-style police interventions.

Many times, this variance in approach can mean the difference between benign and unfortunate outcomes. Teaching police how to better intervene with mental health situations is known as “Crisis Intervention Training” (CIT).

Since its beginnings in Memphis, Tennessee, 25 years ago, the movement towards nationwide CIT for police officers has shown great promise to provide more effective services for those in mental health emergencies, including the potential for diversion to treatment rather than incarceration.

More than 2,000 communities across the United States have adopted CIT programs. Results have been very encouraging, with noteworthy decreases in arrests ,injuries, stigma, and prejudice, and increases in the number of individuals being appropriately diverted for mental health assistance.1

Medical Approach: Ambulance Transport of Emergency Psychiatry Patients

In most U.S. municipalities, when a person in psychiatric crisis calls for help or otherwise activates the 911 system, the responder is commonly a police officer or officers.

Although CIT-trained police officers can make very positive interventionists, they’re also typically charged with transporting individuals in question for mental health evaluation. Some locations require police to transfer crisis patients great distances to receiving facilities, and then wait with them for long hours until a disposition can be determined.

This process has drawbacks for all involved. The crisis patient can undergo the disturbing and stigmatizing procedure of being placed into handcuffs and hauled away in the back of a squad car merely for having suicidal feelings. Meanwhile, strapped police departments lose a valuable officer or officers, who could instead be out fighting crime during those hours.

On top of this, police are not health care professionals, so asking them to assess a situation and determine whether it’s psychiatric or medical, and then make a judgment call on the patient’s treatment destination is not appropriate.

 Anywhere from 15% to 30% of apparent psychiatric emergencies have a medical cause or serious medical co-morbidity.2 If such an illness happens to be life-threatening, time lost when an officer incorrectly transports a patient to a psychiatric intake site may be crucial.

A better approach is beginning to take hold across the country — responding police offers are trained to summon ambulance crews to evaluate the medical condition of individuals with apparent psychiatric crisis.

The healthcare-savvy ambulance teams can assess the situation and transport individuals to the proper destination — be it medical or mental health — or turn care over to mental health mobile crisis personnel, if available and appropriate.

Not only is this a safer protocol, it is much less stigmatizing. It recognizes that psychiatric emergencies truly should have parity and equivalent status as medical emergencies, as they are already defined to be in the federal Emergency Medical Treatment & Labor Act.3 As an added benefit, it frees police officers to quickly return to their duties.

Recovery Approach: De-escalation Rather than Coercion

For many years in most acute care and emergency settings, the default treatment for an agitated patient has been for staff and security to contain or subdue the patient. This has consisted of physically restraining the patient and forcibly injecting involuntary medications — a method otherwise known as “restrain and sedate.”

In the past, any questions about this process might have been dismissed by saying it was the only way to keep patients and staff from harm.

Increasingly, it’s been demonstrated that empathy, verbal de-escalation, and calming techniques can safely diffuse many episodes of agitation in lieu of coercion and that patients then more readily voluntarily engage in treatment.