Mark had just had a couple of beers and already there seemed to be an alteration in his behaviour. His speech was rapid and his language was getting more and more profane. Mark seemed to gulp down his drinks and his eyes seemed to darken, his look was almost evil. Tremors were also noticed especially in the hands and was also getting irritable for no apparent reason.
Until it struck like a volcano. His wife had remarked for his inappropriate language and abruptly, he got up and started hitting her. The worst part of it was that it was infront of the next door neighbours and two kids, one of them being a physically impaired child.
Sonia got angry and ashamed of what was happening , thought that she needed to fight back in order to keep her face. "No, you don’t hit me." Only to irritate him more and receive more blows. Chaos, shouting and crying, especially from the kids, predominated the scene. It had to stop and someone had to take action immediately. Sonia knew she had to be out of that dangerous situation quickly.
She firmly instructed her neighbours to get over the wall to their own roof and get the kids out of the sight of this bizarre attitude, with the thought that it would then be her turn to flea out of that situation. And so they did. Running to safety was an issue as things were uncontrollably wrong and Mark seemed to be disengaged from everything that was around him, except his wife!
Realizing that she couldn’t do anything in her power to beat her husband’s strength, Sonia decided to at least try and reach to Mark by expressing what was happening to her, that he was harming her. She plead him to stop as this was also hurting the boy and it seemed to work for a little while as Mark seemed to lessen the attack. It was then that Sonia managed to jump on the neighbour’s roof but it made Mark furious and managed to grab her by the hand to smash a plate on her face.
It was hell…..the shouting, the crying, the frustrations, the helplessness, but yet Sonia continued trying to stay in touch with her husband by asking him not to hurt her and to think of the boy and not to try to regain control of himself…….until, he eventually let go of her hand and she was able to run to safety. At that time, the psychiatric emergency was over…now it was time to be resolved and police intervention was requested.
Sonia was to stay home together with the boy and Mark and they will try to sort things out, the day after.
What constitutes a threat of violence or psychiatric emergency?
Psychiatric emergency refers to a severe disturbance of mood, thought or behaviour that needs immediate attention (D. Antai. Otong, 2001). This means that the client presents in a clinical or non clinical environment with complaints of acute symptoms, psychological and/or physical distress that overwhelms his or her present coping capacities.
Fauman and Fauman (1981) extended this definition so that it gave some indication of the nature of the problem. They mentioned:
1. Behavioural alteration
2. Mood disturbance
3. Social relationship discordance
4. Thought disorder
5. Overwhelming nature of the problem
6. Prolongued or intense precipitant
7. Reduction in client’s abilities and/or emotional strength at the time of crisis
Features of psychiatric emergencies.
1. Client is extremely agitated
2. Irrational decision making and poor judgement at that time
3. Put extreme demands on others
4. May place himself or others in danger
5. Not aware of the consequences of this danger
6. The client might not be aware or relate to the reality of his surroundings
7. A frightening feeling and distress upon those dealing with the client to whom they will respond spontaneously
Causes of psychiatric emergencies
There is no specific study to illustrate what can cause a psychiatric emergency, but it may be attributed to one of the following dysfuctions:
Brain disorder – people with mental retardation or autism may exhibit aggression in spurts, while appearing docile in between explosions. People diagnosed with attention deficit disorders may also develop sheer frustration, especially if he has not been diagnosed
Recovery from addictions – people who stop using their substances often feel agitated and may exhibit short tempers, impatience, anxiety, impulsivity as the body goes through the withdrawal effect
Trauma to the brain - this may cause the brain to bounce within the skull leading to bruising that in turn impacts the brain’s products of different types of neurotransmitters. The end result is that the individual is overcome with intense feelings of anger and is likely to lash out
Physical, psychological and emotional traumas – such traumas may leave the person psychologically and emotionally imbalanced leading to a lack of ability to cope with life stresses or anti social behaviour
Sudden changes in behaviour – these can be caused by different types of depression, psychoses and schizophrenia. Even medications to treat mental illnesses are known to trigger an alteration
Developing a clinical practice guidelines to deal safely and successfully with threats of violence or psychiatric emergency
People have different reactions when moving into fight/flight mode.
Some people may put the car in drive: they attack
Some people put the car in reverse : they run
Some people can’t decide, so they leave the car in neutral : they freeze
Psychiatric emergencies cannot always be avoided but in most cases, they can be predicted. Appreciating personal safety and that of relevant others is of utmost importance. With such extreme demands upon the person involved in such cases, feelings such as anger, fear, helplessness, loss of face and dignity emerge and these hinder how we effectively respond.
Assessment, intervention, resolution and support (AIRS), states four key elements how to effectively deal with psychiatric emergencies (Martin F. Ward, 1995).
Implementation of Assessment
Mark was already showing an alteration in his behaviour…the increasing profane language, the gulping down of his drinks, the tremors, the darkening of eyes (pupil dilation), were already a sign of acute disturbance.
So, assessment in this case was quite a good predictor.
Assessing the environment.
We know that there was food involved as it was supposed to be a barbecue, so there was a possibility of cutting objects within reach.
We find ourselves on a roof and we take a look at exits….doors, hiding places….in this case, it was a wall
Alone or not alone - in this case, we find the neighbours, together with two kids, so here we add the crying and the shouting to a chaotic atmosphere.
Unlike a street assault where one would be reacting to a complete stranger, we find two people who knew each other. So, there was already an assumption of Mark’s behaviour, reactions and past history.
It was also important to assess Sonia’s reaction…we see her angry and embarrassed at first…..reacting impulsively, leaving Mark more uncontrollable. But when she rationalized situation, she was able to plan a strategy to get out of situation with the least possible harm to herself and others.
Intervention is the part where the assessment is valued and an effective strategy to move out using every tool one can think of is implemented.
We see Sonia confronting Mark with anger at the very beginning leaving him in a more irrational state and herself in a dangerous position. Gaining control of herself was the time where intervention could be valued. This is the part where self awareness is involved. She knew she was acting out of embarrassment and hearing the kids crying was creating more chaos, so providing a calmer environment was demanded and reaching out to her neighbours was her tool.
Accepting her limitations, she instinctively protected herself as much as possible and here, her only tools were the crouching position and her hands.
We see Mark disengaged from reality. Shouting verbal accusations for no apparent reasons….and in an uncontrollable demeanour. Sonia had to get released and so she tried, empathically to reach out to Mark. She was pleading him to stop as she was hurting and it was not good for the boy - she knew his father was compassionate to his son. She was asking him to try and control himself so they could sort out things better - her tool now was constructive communication of self and situation.
So we see that gaining self control and not reacting impulsively, acceptance of own weaknesses and strengths, non verbal and non judgemental communication, empathisation and compassion and instincts were key factors in the outcome of this event.
I love to associate resolution as providing a picture…..the more pixels….the cleaner and clearer the image is provided.
We see Mark, letting go of Sonia. Even though he is still speaking profane and verbally accusing, there seems to be a longer period of quietness. We see him sitting down smoking cigarettes when ordeal was over. Though the anxiety is still present, he is in a calmer state. Sonia is safe, reassuring the kids that everything is better now.
We see a picture which is less critical now and the outcome seems to have reached a positive phase. Now it required confrontation and here is the part where other professionals could be involved. This time, the police.
When the police arrived, they found a calmer Mark, an exhausted Sonia and a helpless boy who was concerned for both parents. After they approached them both and listen to their concerns, they explained the severity of the case and agreed by all involved that they had to press charges. Sonia was to stay at the house, together with Mark and the boy and they would sort things out better the day after.
Both were devastated and seeing their exhaustion and Mark’s cooperation, police suggested that everyone stays in the house and sort out differences. What everyone ruled out was that this was a psychiatric emergency and needed the right approach as if not, it will arise to another psychiatric emergency with unimaginary consequences.
Intervention in emergency settings (IASC, 2003) provide an overview of recommended interventions and support for improving mental health and psychosocial well being. These include:
Basic services and security – well being of people should be protected through establishment of security services, adequate governance and services that address basic physical needs - provide shelter, health care services, law enforcement and adequate communication accessibilities
Community and family supports: represent the emergency response for a smaller number of people who are able to monitor their mental health and psychosocial well being if they are able to be provided by help from family and community – in most emergencies, there are significant disruptions of family and community networks due to stigma, lack of education, fears and distrust, so people will benefit from help within community and family supports
Focused non-specific support: represent support for the still number of people who additionally require more focused individual, family or group intervention by trained and supervised workers. These include support from basic mental health care by primary health care workers.
Specialized services: these represent an additional support required for the small percentage of population whose suffering despite the support already mentioned is intolerable and may have difficulties in basic daily functioning. Assistance include psychological and psychiatric support for people with severe mental disorders whenever their needs exceed the capacities of existing primary/general health services. Such problems require either (a) referral to specific services, (b) initiation of longer term training and supervision of primary/general health care providers.
As we’ve seen, psychiatric emergencies are often unstoppable and would require super human resources and insight to be able to predict and manage. Also, there is no control where they can take place.
Importance of educating people especially professionals on what constitutes such emergencies in this case is beneficial and knowing about reachable resources is of utmost importance.
Culture may also impair effectiveness of approach due to stigma.
Usage of medication may also be needed to tackle such events, but mainly dealing effectively with crisis may inhibit further episodes of psychiatric emergencies and people involved should be open to all the support they can be able to get.