STAT Op-Ed with Vituity's Denise Brown MD on How to Stop the Dehumanization of Behavioral Health Patients


As Featured on STAT

July 2, 2019

If you go to a hospital emergency department (ED) with symptoms of a physical emergency such as chest pains or symptoms of a stroke, you’re likely to be met by a team of doctors and nurses who know exactly what to do. They will assess you quickly and competently using an established protocol. Most of them will be compassionate and kind, making the patient feel safe and cared for.

Denise Brown, MD

But what if you or a loved one walk through those ED doors having an acute behavioral health crisis? Maybe you’re hearing voices or have attempted suicide. You’re upset and scared – probably agitated, irrational, and disoriented.

The reaction from health care workers may be quite different. You or your loved one may have to wait hours in a crowded, noisy waiting room, or in some cases in a locked examination room, possibly restrained or monitored by a guard. The worst case scenario could involve being left on an emergency department gurney for hours – or even days – until an inpatient psychiatric bed, the default treatment, becomes available.

Here’s the bottom line: EDs often treat psychiatric patients as less than human. Too frequently, our current approach escalates what is already a tenuous, scary and traumatic situation for everyone.

What’s worse is we’re up against some pretty frightening numbers. ED visits for suicidal ideation and suicide attempts more than quadrupled between 2006 and 2014. Behavioral health emergency department visits overall increased by nearly 57% for children and 41% for adults during a similar time period. And every ED across the country has witnessed the explosion of opioid overdoses – another tragic manifestation of untreated mental illness.

In my 20 years as a physician, I know first-hand that addressing this great need begins with changing the way we relate to these patients. As University of Houston research professor, Brené Brown says, “To know pain is human. To need is human. And, no amount of money, influence, resources, or sheer determination will change our physical, emotional, and spiritual dependence on others. Everyone has a story or a struggle that will break your heart. And, if we’re really paying attention, most people have a story that will bring us to our knees.”

The most effective tools we can use are ones we already possess – empathy, kindness and a mindset of treating people the way we would want to be treated. In practice, this EmPath model – which stands for “Emergency Psychiatric Assessment, Treatment and Healing unit” – creates a safe space specifically designed to calm and stabilize patients in behavioral health crises.

What does this look like?   

  • A calm environment. Instead of making a patient in crisis wait in the noise and chaos of an ED, EmPath units offer a quiet, darkened space with comfortable chairs to help relax patients.
  • De-escalation. We’ve seen patients who come in frightened, angry, or out of control on drugs. While some of them cannot be calmed down by simple dialogue, a surprising number can. Speaking slowly and quietly and assuring them, “we’re going to get through this together,” goes far to reduce aggression and build trust that you are there to help.
  • Immediate access to a psychiatrist. In the EmPath model, every behavioral health patient is seen right away by an emergency psychiatrist. If there is not one available on site, we provide access over video. And we’ve seen that remote telemedicine consults are effective for emergency psychiatry. In fact, many patients find it easier to open up and be vulnerable when the person they’re talking to is on a screen.

This approach delivers substantial benefits. First, the focus on immediate care means patients get treated and discharged instead of being admitted; we’ve seen a 75% drop in hospitalizations. In the same way, we avoid “boarding,” the practice of leaving patients on gurneys while ED staff try to place patients with open inpatient beds. Eighty percent of our patients go home within 16 hours.

Like most changes in care delivery, this one will not be fixed from the top down. Physicians and administrators need to listen to the people on the front lines: most importantly nurses, but also paramedics and social workers.

By adapting outdated processes and procedures and empowering providers to deliver quality care for all patients, we reinvigorate healthcare providers to experience passion for their work. At the same time, it provides improved outcomes and a better experience for patients. Most importantly, it helps patients know on a very human level that they’re receiving proper care and provides communities with the confidence and comfort of knowing their local EDs can be trusted in dealing with a healthcare crisis.