Family-Based Crisis Intervention in the Emergency Department: A New Model of Care
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- Ginnis, K.B., White, E.M., Ross, A.M. et al. J Child Fam Stud (2015) 24: 172. doi:10.1007/s10826-013-9823-1
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Adolescent suicide is on the rise and treatment resources are scarce. Adolescents with suicidal behavior often are evaluated in the Emergency Department (ED), where the default treatment recommendation traditionally has been admission to an inpatient psychiatric unit. Emergency Medicine increasingly provides intervention in the ED with the goal of stabilization and discharge, avoiding unnecessary inpatient stays that are expensive and utilize limited resources. Family-Based Crisis Intervention (FBCI) is a manualized psychiatric intervention that is used to optimize care for suicidal adolescents and their families in the ED. This paper presents the framework of FBCI and includes a case to demonstrate the essential parts of the treatment.
KeywordsSuicideAdolescentCrisis interventionFamily therapyEvidence-based practice
Adolescent suicide persists as a significant public health problem. A number of studies indicate dramatic increases in pediatric suicide rates in the past 10 years (Center for Disease Control 2007, 2008; Center for Disease Control and Prevention 1998, 2007; Office of Disease Prevention and Health Promotion 2000). In 2007, suicide was the third leading cause of death in children ages 10 through 24, exceeded only by unintentional injury and homicide (McIntosh 2010). In addition, the American Association of Suicidology (AAS) estimates that approximately 100–200 attempts are made for every completed suicide by youth between the ages of 15–24 (McIntosh 2010). Moreover, prior suicide attempt is a salient risk factor for eventual suicide completion (McIntosh 2010). Over the past 5 years, hospitals have begun to recognize the importance of suicide assessment and prevention. Since 2007, The Joint Commission, which accredits hospitals in the US, has required that hospitals use established early identification and assessment tools to manage patient suicide risk. The establishment of the reduction of suicidal behavior in adolescents was again included as a 2010 National Patient Safety Goal within the Joint Commission Hospital Program (The Joint Commission 2009).
Studies have shown that suicidality in adolescents has been the most significant factor in the majority of Emergency Department (ED) visits for behavioral health concerns (Stewart et al. 2006) and the most common presenting problem for adolescents subsequently admitted to an inpatient psychiatric unit (Brooker et al. 2007). Suicidal adolescents in the ED are at increased risk for boarding; defined as extended stays in the ED or another non-psychiatric setting while awaiting psychiatric placement (Mansbach et al. 2003; Wharff et al. 2011). Prolonged ED stays have both clinical and systemic implications. Clinically, boarding in the ED delays access to treatment for suicidal patients. Systemically, patients who are boarding utilize personnel and other resources (such as rooms), which delays cares for waiting patients, ultimately impacting the quality of and satisfaction with their care as well as clinical outcomes(Bernstein et al. 2009; Rabin et al. 2012).
In current Emergency Psychiatry practice, suicidal adolescents who present to the ED have medical and psychiatric evaluation, with little or no psychiatric treatment provided in the ED (Bruffaerts et al. 2008), often followed by psychiatric hospitalization. The focus of ED assessment is usually “disposition:” what does the patient need, and where and how can s/he get that treatment? There is little evidence in the literature or in clinical practice of psychiatric intervention that occurs exclusively in the ED. To date, only two studies outside of our work have evaluated outcomes based on an ED intervention for suicidal adolescents (Asarnow et al. 2011; Rotheram-Borus et al. 1996, 2000). In a previously published open trial (Wharff et al. 2012) we demonstrated that FBCI can successfully decrease the need for inpatient hospitalization through stabilization in the ED.
Mental health professionals have long understood that a crisis represents an opportunity for significant change (Aguilera and Messick 1990) (Parad 1965), when the usually rigid boundaries of a system are more fluid and open to intervention. In this paper, we present the Family-Based Crisis Intervention (FBCI), a single-session ED-based intervention designed to reduce suicidality in adolescents by working with the teen and his/her family members at the time of crisis. We developed this intervention in response to our clinical observations in the ED: families whose child was in psychiatric crisis in the ED were open to intervention and could be enlisted to help their child, given appropriate clinical tools and supports.
The case of “Tina” that follows illustrates practical application of FBCI. Using the traditional emergency psychiatry model, Tina would be admitted to inpatient psychiatry based on the severity of her initial presentation. The case demonstrates how the different components of FBCI provided the support and education that Tina and her parents needed to decrease her suicidality, eventually leading to her discharge home from the ED. Although non-lethal, an intentional ingestion of this magnitude typically results in admission to a locked inpatient psychiatric unit. All identifying information has been changed to protect the identity of the patient.
The Case of Tina
Tina is a 15 year old girl who presented to the ED after ingesting approximately 80 tablets of 200 mg ibuprofen. After the medical team evaluated Tina and determined that there was no need for medical admission or further treatment, a psychiatry clinician (in this case a psychiatric social worker) assessed Tina. As is standard in psychiatric evaluation of adolescents, the clinician met separately with Tina and her parents in order to obtain a thorough history, to assess mental status, and to formulate the case.
During her interview, Tina reported to the clinician that her ingestion was, in fact, an attempt to end her life, and that the primary precipitant for her suicide attempt was a fight that she had with her parents immediately before she ingested the pills. She reported that she had a good relationship with her parents, but that she was afraid of disappointing them. By the time Tina was assessed in the ED, she endorsed feeling “ashamed and guilty” for having made an attempt and “relieved” that the attempt was not successful.
During the interview with Tina’s parents, they seemed to understand the severity of their daughter’s suicide attempt, but also referenced a prior negative experience with another family member’s psychiatric admission. Both parents were shocked and frightened by Tina’s suicide attempt, as neither was aware that Tina had been feeling depressed or suicidal. They were concerned with ensuring that they responded appropriately to their daughter’s distress.
Following the initial assessment, the clinician utilized the core components of FBCI to stabilize Tina and to explore all treatment options with the family.
Joint Crisis Narrative
The Joint Crisis Narrative is the crux of FBCI, and differentiates this intervention from standard emergency psychiatric care. This concept is based on the idea that adolescents and their caregivers frequently arrive in the ED with different stories about what precipitated the suicidal crisis. The disequilibrium inherent to the crisis (Parad 1965) allows the clinician to intervene in ways that the family might otherwise resist under different circumstances. When conducting FBCI, the clinician seizes this opportunity to help the caregivers and adolescent understand each other’s perspective, thereby creating a single, unified crisis narrative that incorporates aspects of their previously disparate accounts of what transpired.
In her meeting with the clinician, Tina expressed a common explanation of what precipitated her suicide attempt: that she was completely isolated from both her family and her peer group, and that her parents would “never” understand her. Her parents’ initial angry reaction in the ED reinforced Tina’s feelings of isolation.
As is the case with many suicidal adolescents, Tina’s parents knew little about the severity of her distress until she attempted suicide. Tina’s parents were not aware that she was depressed or that she had been experiencing suicidal thoughts. They mistakenly interpreted her moodiness and irritability as normative adolescent behavior, and may have unknowingly minimized symptoms that were overwhelming for Tina. In these situations, clinical intervention often involves altering the caregiver’s perception: leading the caregivers through their shock, denial, and grief about the extent of their child’s distress. Initially, Tina’s parents’ overt anger masked their underlying feelings of disbelief, grief, shock and fear. A separate meeting with Tina’s parents allowed them first to express their anger, then to discuss their fears and concerns, and eventually to reframe their anger at her behavior as concern about her depression.
After working independently first with Tina and then with her parents, the clinician brought the family together. An essential tool of the family meeting is perspective-taking, and Tina and her parents were each able to express a better understanding of the other, moving from their individual disparate narratives to a Joint Crisis Narrative. Tina expressed her fear of disappointing her parents and her concern that they did not love her. She also acknowledged that her complete isolation from them had been contributing to her feelings of hopelessness. Her parents apologized for their initial angry responses and reassured her that they were scared, not angry. As they recounted the events that preceded her suicide attempt, both Tina and her parents were able to identify situations in which each had misinterpreted the other’s words or actions. Together, they came to recognize how misunderstanding led to miscommunication and eventual alienation. Aided by the clinician, Tina and her parents co-created a Joint Crisis Narrative that enabled them to move from the crisis point to a new equilibrium with greater mutual understanding.
In this FBCI module, the clinician provides psycho-education about depression and suicidality for the adolescent and caregivers. The clinician uses the adolescent’s narrative to make connections between the parameters of her symptoms (triggers, extent of, duration, precipitant and current coping skills) and the facts about depression.
Tina acknowledged that her feelings of sadness had been building for a few months and appeared to be related to decreased contact with her sister, who had moved away, bullying at school, and feelings of social isolation. Her parents learned that the fight that immediately precipitated Tina’s suicide attempt was only a portion of the narrative, which helped them to understand her motivation. The clinician noted to the parents that depression had distorted Tina’s thinking about her relationship with her parents, which then exacerbated to her suicidal thinking and behavior.
During the meeting with Tina’s parents, the clinician provided a great deal of factual information about adolescent depression and emphasized the importance of regular on-going therapeutic and/or psychopharmacological treatment. Having dealt with adult depression in the family, the parents were surprised to learn that their daughter’s disengagement, “boredom,” and irritability were symptoms of depression. This module increased their empathy for Tina; they were able to connect her longstanding “difficult” behaviors to depression, when previously they interpreted them as oppositional.
Cognitive Behavioral Skill Building (CBT)
This module provides education about CBT and teaches skills to the patient and family during the ED visit. There is a strong body of literature that supports their use in decreasing depressive symptoms (Klein et al. 2007; Spirito et al. 2011).
First, the clinician provided basic information about CBT to Tina and her parents. The family learned that there is an interaction between thoughts, feelings, and behaviors, and that intervening with negative thinking and counterproductive behaviors can have a positive impact on mood. Specifically, they learned to use CBT skills of cognitive restructuring, behavioral activation, and problem-solving.
Tina expressed “all or nothing thinking,” a cognitive distortion typical of depression (Burns 1999). Through FBCI, Tina and her parents learned that cognitive distortions are a hallmark feature of depressive thinking. The clinician taught Tina how to identify and evaluate her automatic thoughts. Similarly, the clinician taught her parents how to coach her to question herself when they observe that she may be engaging in distorted thinking.
Tina engaged easily in identifying activities that would help her feel better, including confiding in a close relative, exercising, drawing, and participating in theater activities. Together, the family generated a number of specific activities, such as going to the gym, watching a movie, or attending a theater group. They decided to schedule activities together at least 3 times per week to prioritize activities that would contribute to Tina’s improved mood.
The family learned the steps of problem solving, (identifying a problem, generating possible solutions, trying one of the solutions, and systematically trying others as needed if the first solution did not help), and engaged in problem-solving with the clinician in the ED. The identified problem was Tina’s suicidality. The possible solutions were generated and prioritized as follows: (a) discuss with parents, (b) utilize coping skills, (c) schedule a pleasant activity, and (d) seek crisis evaluation. Tina and her parents understood that that in the future they could utilize the steps of problem solving modeled by the clinician in the ED.
The concrete CBT strategies served to mitigate the family’s anxiety and provided a framework with which to manage potential future crises. Tina’s mother indicated that learning the CBT skills and strategies increased her feelings of competence and empowered her to help Tina manage her depression.
The Therapeutic Readiness module is designed to help the adolescent and caregivers understand and acknowledge the importance of ongoing therapeutic intervention. It is designed to “demystify” mental health treatment, and to help family become an educated consumer of mental health services. Families arrive with a variety of knowledge, experiences, and preconceived notions about mental health treatment. Failing to provide education about treatment options may prevent the family from following through with treatment recommendations.
Initially, Tina’s parents were hesitant to engage in a conversation with the clinician about therapeutic assistance. Although the psycho-education and CBT skills had prepared them for the inevitability of acute support for Tina, their previous challenges with the mental health system left them skeptical that therapeutic intervention would help her. Specifically, Tina had a previous therapist whom she and parents did not experience as helpful. Both Tina and her parents benefitted from learning about different treatment modalities. In the therapeutic readiness module, the clinician focused on helping both Tina and her parents be good consumers of mental health services. They learned about therapeutic “fit,” and that different treatment modalities can help different clients. Knowing that there are varied psychotherapeutic treatments and giving them a voice in the decision-making process allowed Tina and her parents to comfortably pursue follow-up care for Tina.
Safety planning is an integral component of FBCI; it is the aspect of FBCI that is most similar to traditional psychiatric crisis evaluation. It should be noted that the safety planning module is not equivalent to a “contract for safety,” a technique where a clinician asks the patient to sign a “contract” that s/he will not attempt suicide, which has been shown in the literature to be ineffective in preventing future suicidal behavior in people who have attempted suicide (Lewis 2007).
In Tina’s case there were two essential ingredients involved in safety planning: (1) developing a comprehensive personal safety plan for Tina, including a back-up plan to pursue if she began to feel suicidal in the future; and (2) teaching her parents how to help Tina maintain safety at home. Because Tina’s triggers were related to feeling alienated from her parents, peer issues, and the lack of a consistent supportive person in whom she could confide, her safety plan focused on developing practical coping skills and building her support system. Tina and her parents scheduled frequent check-ins for the first days after discharge from the ED; they also identified a school staff member who could both address the reported bullying and provide support for Tina.
The clinician educated Tina’s parents about means restriction. They assured the clinician that there were no firearms in the home, planned to monitor knives and sharp objects and to restrict access to medications.
Tina identified her mother and two other adults in whom she could confide in the event that her symptoms persisted or worsened. Tina’s parents also developed a parent safety plan that included monitoring changes in Tina’s behavior, increasing her supervision. Finally, the family was given criteria to assess the need for a return to crisis services.
After Tina and her parents participated in FBCI and, with support, co-created a Joint Crisis Narrative, they were ready to discuss treatment planning. Tina’s parents continued to be wary of mental health treatment in general, and felt as though an inpatient hospitalization was unnecessary. At this point in the intervention, Tina quite clearly denied feeling suicidal, and her parents felt assured that they could safely care for her at home; however, they agreed that continued intensive treatment for stabilization might be helpful. The clinician explained that an acute day treatment program would offer the stabilizing treatment Tina needed while allowing her to remain at home with her family. The family agreed to seek care and, because the family had taken ownership of this plan, they were highly committed to implementing it. They noted that they felt empowered to address problematic family dynamics in conjunction with Tina’s treatment. Rather than feeling forced into a treatment plan which might further alienate and distance them from one another, the family expressed hope and optimism that things would improve.
As part of the FBCI research protocol, Tina and her parents participated in follow-up telephone calls for a period of 1 month after the ED visit. During that month, Tina engaged in outpatient treatment and her family was supportive of her progress. Tina continued to have symptoms of depression, but she reported using clinical supports and the improved relationship with her family to ameliorate her symptoms and she did not require further crisis evaluation during that time. Both Tina and her parents reported improved individual and family functioning, and expressed gratitude for the opportunity to participate in FBCI.
Family-Based Crisis Intervention represents a paradigm shift away from traditional emergency psychiatry practice. It is based on the assumptions that (1) there may be better alternatives to treat a suicidal crisis than inpatient hospitalization, (2) families/caregivers want and are able to provide support to an adolescent family member if given both an opportunity and effective tools to utilize, and (3) a family that learns to support their adolescent while s/he is in crisis will be empowered to continue to provide ongoing support once the acute psychiatric crisis subsides. While all components of FBCI are essential to the intervention, experienced clinicians can flexibly utilize different modules depending on an adolescent and caregiver’s needs. The goal of FBCI is to help the patient and family/caregivers engage in crisis intervention to reduce the patient’s suicidality.
Co-Creation of the Joint Crisis Narrative
The co-creation of a Joint Crisis Narrative enhances the reflective capacity of each family member to better understand the experience of the other(s) and to develop more adaptive and feasible ways of managing suicidal ideation and behavior. With reduced suicidality, more treatment options (e.g., options other than an inpatient hospitalization) become available to the patient and his/her caregivers. During FBCI, the patient and caregivers are able to engage with the provider around an evaluation of the relative benefits of these treatment options, as opposed to simply being relegated to an inpatient facility. Tina and her parents readily engaged with the clinician to learn to support Tina in order to expand her treatment options.
Family-Based Crisis Intervention provides the adolescent and family with the message that, despite adolescent suicidal ideation/behavior, there are skills that families can learn that will enable the adolescent to alleviate or manage his/her distress. Furthermore, the family may feel empowered to be the coordinator of and participant in their child’s care. Families who are initially unable or unwilling to connect to mental health services may be more inclined to commit to seeking services for the family and/or adolescent in times of crisis, both in the ED setting and once the adolescent has been discharged.
In addition to the tangible parts of the intervention, FBCI also instills hope in families who arrive at the ED overwhelmed, anxious, and worried for their child’s survival. Facilitated co-construction of a Joint Crisis Narrative allows the family and adolescent to develop empathy and mutual understanding that promotes reduced symptoms and improved family functioning.
We contend that the avoidance of inpatient psychiatric admission for suicidal adolescents has several benefits for the adolescent, family, and the healthcare system.
For adolescents, psychiatric hospitalization can have long-term effects on self-esteem and perception of their ability to recover (Hellzen and Lilja 2008), as well as their family and friends’ perceptions of their illness. Despite the reduction of societal stigma associated with mental health problems, the stereotypical view of adolescent inpatient psychiatric care depicted in popular literature and films does prevail. When adolescents require psychiatric hospitalization, the interruption inherent therein affects all realms of life, including school, work, family, and peer relationships. Adolescents may lose ground in domains where they are functioning well, which may ultimately contribute to increased symptoms and further reliance on the mental health system.
Family-Based Crisis Intervention relies on identifying inherent individual and family strengths and garnering available supports. The combination of natural supports and traditional outpatient mental health services can provide clinically indicated treatment, thereby avoiding hospitalization. In Tina’s case, her parents were able to identify both therapeutic supports and changes they could make to enhance their capacity to maintain Tina’s safety. Tina and her caregivers were greatly relieved to return home together.
Family-Based Crisis Intervention requires ED clinicians to extend the amount of time that they spend with a patient and family. At first glance, FBCI appears counter-productive given ED time constraints and the recent emphasis on decreasing wait times and improving patient flow (Hoot and Aronsky 2008; Hoot et al. 2009a, b; McCarthy et al. 2008; Nicks and Manthey 2012). Practically, FBCI can decrease patient length of stay if patients are discharged home. Patients who board in the ED have extended lengths of stay while awaiting a psychiatric bed, whereas those who are able to be stabilized and discharged home avoid prolonged ED stays.
Acute inpatient psychiatric care is a limited resource. In many states, seasonal high volume leads to long waits, sometimes for days, in EDs or on medical units. While in the ED or a medical unit, psychiatric patients receive little or no psychiatric care, prolonging their time outside of the home environment without adequate treatment. In addition, boarding presents management problems in EDs (Hoot and Aronsky 2008) and on medical floors for patients who need care that they are not getting. Boarding also creates backup and overcrowding in medical EDs and on medical inpatient units (American College of Emergency Physicians (ACEP) 2008) contributing to longer wait time and delays for patients in those settings (Camilli and Martin 2005; Nicks and Manthey 2012).
The assumption that all suicidal adolescents must be hospitalized is pervasive; however, empirical evidence has yet to show the superiority of inpatient care in effectively reducing rates of suicidal ideation, non-lethal attempts, or completed suicide among adolescents (Gould et al. 2003); More cost-effective alternatives to inpatient hospitalization, such as multi-systemic therapy (MST) (Henggeler et al. 2003; Huey et al. 2004) and rapid-response outpatient models (Greenfield et al. 2002) have been shown to be as effective as inpatient hospitalization for treating suicidality in adolescents who present to the ED. In one study of youth randomly assigned to MST or inpatient hospitalization, rates of youth self-reported attempted suicide at 1 year follow up were significantly lower in the MST group than the sample of admitted adolescents (Henggeler et al. 1999). In another study, significantly lower rates of depressive symptoms were reported at 18 month follow up by suicide attempters who received specialized ED care compared to those who received TAU (Rotheram-Borus et al. 2000).
Tina’s case demonstrates that with acute family intervention in the ED, an adolescent can be safely discharged with her parents. Moreover, she was able to engage in a less restrictive form of treatment and acquire treatment more expediently than if she had awaited inpatient placement. Had a clinician not provided treatment to Tina and her parents in the ED, she likely would have spent at least one night in the ED due to lack of immediate inpatient bed availability. Instead, she received immediate treatment for her acute symptoms, avoided unnecessary use of limited ED and impatient resources, and returned home to her family and community. Tina’s discharge plan included intensive follow-up services similar to those described above.
Implications and Future Directions
Emergency Medicine providers utilize a model of care that depends on triage and treatment prior to decision-making about disposition. There is an increasing reliance on the development and translation of evidence-based practices for many conditions in the ED (Iyer et al. 2011). It is imperative that emergency psychiatry follow suit. Emergency psychiatry clinicians must have tools to provide immediate care during a crisis, rather than simply moving a patient and family from one place to another.
The prevailing model of emergency psychiatric care should include stabilizing interventions; however, such interventions must be tested before clinicians adopt them into their practice. FBCI is a model of care for suicidal adolescents that may be a viable alternative to traditional ED care that presumes inpatient care as an endpoint. We are currently evaluating the efficacy of FBCI through a randomized clinical trial, and hope to progress to effectiveness studies in the near future.