2023 14th Annual NUBE Conference

I present this lecture from the biopsychosocial perspective. As always, the points are mostly based on clinical examples, and I attempt to make audience learning experiential, with participants having the feel of being in the room with a patient. The talk is two things: 1) a brief meditation on the identity, achievements, and perils of emergency psychiatry as a discipline; and 2) a brand new installment in the ongoing task of improving our understanding of hard-to-engage and hard-to-read crisis patients, and improving our ability to work with them.What is emergency psychiatry? It’s the offspring of two parent disciplines, emergency medicine (EM) and psychiatry, but it’s also a unique discipline in its own right, sometimes reflecting the ethos and concepts of one parent, sometimes the other. Neither one mindset or set of skills is sufficient.This idea is developed using the examples of agitation/de-escalation and suicide risk assessment and management. For example, EM teaches us how to act immediately and decisively, authoritatively, and what the bedrock principle is that justifies this, while psychiatry teaches us to engage the patient as we help him de-escalate himself. But what is really taking place on a micro level? How do we shift gears without slowing down? How do we defend ourselves against the criticism of treating without evaluating? We review and re-examine this classic material and discover new insights. Current practice, as well as the limits of our knowledge, are illuminated.Similarly, in the case of suicide assessment, our ever-pragmatic EM background teaches us to make important level-of-care decisions in a relatively short period of time with often a limited amount of hard information. But psychiatry teaches us to tease out the subtleties, caveats and the potential drawbacks of this style of practice. A number of these are explored. For example, should the goal be to amass ever-larger quantities of data for an algorithm to synthesize into a level of risk, or should we find a way to work with the patient and develop a small amount of choice data that forms the basis of a collaborative assessment?This talk delves more deeply than any of my past talks into what is commonly thought of as intuition, ie, the thing that “can’t be taught”. Audience members are given the opportunity to (privately) examine their own internal reactions to a patient. The idea of the interpersonal field is introduced. Our feelings can be very specific co-creations of contrasting states within the patient, feelings which can tip us off to a piece of the individual that wants to engage. The profound implications of this are explored. Finally, what do we do when patients we have seen before and referred out return in a partially-treated state and fill up our PES’s and ED’s? One answer: return to a classic EM paper, that the ED is a “room with a view” (1). Again, EM is a crucial bedrock for emergency psychiatry.

Learning Objectives:

1. To be able to describe the ways in which emergency psychiatry is a dynamic blend of elements from emergency medicine and general psychiatry, which are at times complementary, at times in opposition.
2. To be able to describe some of the highlights and pitfalls of emergency psychiatry as a unique discipline.
3. To appreciate on an experiential level how our internal reactions to a hard-to-read patient can tip us off to a guarded or inarticulate piece of the individual that wants to engage. To see how developing this awareness can hasten de-escalation, enhance suicide assessment, and increase engagement in recovery.